Program Design And Implementation

Transcription

Part V
Program Design and
Implementation
Chapter 12
Weight-management
Programming
Chapter 13
Exercise
Programming
Chapter 14
Nutritional
Programming
Chapter 15
Lifestyle
Modification and
Behavior Change
Chapter 16
Adherence to
Physical Activity and
Weight-loss Behaviors
Fabio Comana
Fabio Comana, M.A., M.S.,is an exercise physiologist, research
scientist, and spokesperson for the American Council on Exercise.
He also currently teaches courses in exercise science and nutrition
at the University of California, San Diego and San Diego State
University. Comana regularly presents and writes on many topics
related to exercise, fitness, and nutrition, and has authored or
co-authored more than three dozen articles and chapters in various
publications. He has master’s degrees in exercise physiology
and nutrition, and currently holds certifications from ACE, the
American College of Sports Medicine (ACSM), the National Strength
and Conditioning Association (NSCA), and the International
Society of Sports Nutrition (ISSN).
Chapter 12
Weight-management
Programming
I
n 2006, 72 million American dieters spent $55 billion in the
weight-loss market, and forecasts estimate that amount to reach
nearly $69 billion in 2010 (Marketdata Enterprises, Inc., 2007).
According to the Centers for Disease Control and Prevention (CDC),
there has been a rising trend of Americans considered overweight
and obese: from 65.7% and 30.6% in 2001–2002 to 66.3% and
32.2% in 2003–2004, 68% and 33.8% in 2005–2006, and 68.3% and
33.9% in 2007–2008, respectively (Table 12-1).
An effective weight-management program involves a
multidisciplinary team approach that includes a physician,
registered dietitian, exercise physiologist, and behavioral
therapist. Through this team approach, the three critical areas—
behavior and lifestyle modification, nutrition, and physical
activity—can be coordinated. While this approach is ideal, the cost
of employing a team of healthcare experts, combined with the lack
of third-party reimbursement, creates potential barriers. Hence,
IN THIS CHAPTER:
Introduction to
Effective Weight Management
Components of an Effective Weightmanagement Program
Prevalence of Obesity
Population Statistics
Health Objectives
Safe and Effective Weight Loss
Understanding Behavioral Change
Transtheoretical Model of Change
(Stages of Behavioral Change)
Stages of Change
Processes of Change
Decisional Balance
Self-efficacy
Tracking Progress and
Keeping Records
Participation and Activity Logs
Emotional Association With Programming
overweight or obese clients may instead opt to seek the services of
competent allied health professionals who are experienced in all
three disciplines and have an established referral network in place.
The success of a Lifestyle & Weight Management Coach (LWMC)
necessitates proven competencies in these areas and the ability to
address the individualized needs of clients. The science behind each
area is discussed earlier in this book, while the subsequent chapters
focus on programming guidelines and strategies.
Strategies for Overcoming Obstacles
Barriers to Participation
Relapse Prevention
Summary
Chapter 12 Weight-management Programming
Introduction to Effective
Weight Management
Components of an Effective Weightmanagement Program
LWMCs can expect to encounter obstacles, either identified or reported by their
clients, during the early stage of their relationship. During the interview and information-gathering stage, LWMCs may identify
internal and external barriers. Internal
barriers could be anxieties, ambivalence,
or defensive avoidance, such as rationalizing a decision to delay starting a program.
External barriers could be the inconvenience
of the program, lack of time, or lack of support (Griffin, 2006).
While LWMCs have the best intentions
for their clients, they must act ethically
and responsibly to determine what is appropriate, given the client’s current stage
of behavioral change. LWMCs must never
assume that a meeting with a client means
that he or she has entered the preparation or action stage of behavioral change,
and is therefore ready to move forward.
LWMCs must be skilled in identifying a client’s current stage of change and have the
ability to implement or recommend the
appropriate strategies. This is a critical first
step toward facilitating a more permanent
lifestyle change. Time and money invested
in a nutritional or activity/exercise program
may be wasted if the client’s underlying
psyche is not addressed first. The subsequent chapters address individual programming components of lifestyle and behavioral
modification, exercise, and nutrition.
In general, the design of effective
weight-management programs for clients
requires that LWMCs gain a working knowledge of the following skill sets.
Lifestyle and behavior modification:
•R
eadiness to change behavior and identification of current stage of change
• P rocesses of change (cognitive and/
or behavioral) and the shifting of a cli264
L if estyle & W eigh t Man agem en t Coach Manual
ent’s decisional balance toward change
(Prochaska & Marcus, 1994)
• Self-esteem, self-efficacy, and selfefficacy-building strategies
• Acknowledgement of, and reframing of,
current attitudes, perceptions, apprehensions, and belief systems
• Value of cognitive techniques, such as
goal-setting
• Rapport building and maintenance
• Effective verbal and nonverbal communication, and good listening skills
• Different personality styles (e.g.,
technical, sociable, or assertive) and
appropriate communication styles
(Griffin, 2006)
• Support systems
• Internal and external barriers and
obstacle management
• Appropriate cognitive, motor-skill, and
affective learning techniques
• Motivational strategies, including
reinforcements, antecedents, rewards
(extrinsic to intrinsic), personal contracts, stimulus control, and self-talk
Exercise programming:
• Exercise science
• Health-risk assessments and risk
stratification
• Referrals to appropriate professionals,
confidentiality, and SOAP note format
• Exercise and testing contraindications
• Physiological assessments and termination criteria
• Limitations of assessments and the
interpretation of criterion-referenced or
norm-referenced data
• Program design and implementation
• Environmental effects
• Reevaluation and modification/
progression
Nutritional programming:
• Nutrition (macronutrient and micronutrient function) and digestion
• Nutritional assessments
• Caloric balance and weight-management-program design
American Council On Exercise
Weight-management Programming
• Dietary guidelines, labels, and portions
sizes
• Weight-loss diets and supplements
• Dietary needs for special populations,
women, and vegetarians
Prevalence of Obesity
Population Statistics
The National Health and Nutrition
Examination Survey (NHANES), which is
conducted every 10 years by the National
Center for Health Statistics (NCHS) and the
CDC, assesses the health and nutritional
status of adults and children in the United
States. It is arguably the largest and longest-running longitudinal health survey of
the U.S. population and provides valuable
information on important health indicators. The prevalence of overweight and
obesity has been tracked since 1971, and
a rising trend is evident within the U.S.
population (Table 12-1). In 2008, an estimated 154 million adults were overweight
or obese; among women 20 years and older,
more than 97 million were overweight, and
more than 49 million were obese.
According to the CDC, the average
male weighed 166.3 pounds (75.5 kg)
in 1960–1962, while the average female
weighed 140.2 pounds (63.7 kg). By contrast,
in 1999–2002, the average male weighed
191.0 pounds (86.7 kg), while the average
female weighed 164.3 pounds (74.6 kg).
Chapter 12
The increased incidence of obesity is attributed to decreasing levels of activity and
increasing access to, and consumption of,
food. Physical-activity statistics from the
Department of Health and Human Services
and the Centers for Disease Control and
Prevention in 2007 indicated that only 48.8%
of U.S. adults were achieving the recommended physical-activity levels consistent
with the U.S. Surgeon General’s report; 37.7%
were insufficiently active (defined as more
than 10 minutes total per week of moderateor vigorous-intensity lifestyle activities, but
less than the recommended level of activity);
13.5% of adults were inactive (defined as less
than 10 minutes total per week of moderate- or vigorous-intensity lifestyle activities).
Likewise, the average consumption of calories in adults increased by 12%, or 300 kcal,
between 1985 and 2000.
Being overweight or obese significantly
increases the risk of developing serious disease and health conditions, including the
following:
• Hypertension
• Dyslipidemia
• Type 2 diabetes
• Coronary heart disease
• Stroke
• Gallbladder disease
• Osteoarthritis
• Sleep apnea and respiratory problems
• Some cancers (endometrial, breast,
and colon)
Table 12-1
Age-adjusted Prevalence of Overweight and Obesity Among U.S Adults, Ages 20–74
NHANES II
(1976–1980)
(n = 11,207)
NHANES III
(1988–1994)
(n = 6,679)
NHANES
(1999–2000)
(n = 4,117)
NHANES
(2001–2002)
(n = 4,413)
NHANES
(2003–2004)
(n = 4,431)
NHANES
(2005–2006)
(n = 4,356)
NHANES
(2007–2008)
(n = 5,555)
Overweight or Obese
(BMI >25.0)
47.0%
56.0%
64.5%
65.7%
66.3%
68.0%
68.3%
Obese (BMI >30.0)
15.0%
22.9%
30.5%
30.6%
32.2%
33.8%
33.9%
* Age-adjusted by the direct method to the year 2000 U.S. Bureau of the Census estimates using the age groups 20–39, 40–59,
and 60 years and over.
Source: National Center for Health Statistics, Centers for Disease Control and Prevention
Lifest yle & Weight Management Coach Manual
265
The Centers for Disease Control and
Prevention had previously reported that
obesity is responsible for more than 356,000
deaths a year, a number that has increased
by 33% over the past decade and may soon
overtake tobacco as the leading preventable cause of death among Americans. More
recently, a study based on a nationally representative sample of U.S. adults estimated
that approximately 112,000 deaths are associated with obesity each year in the United
States (Mokdad et al., 2004; 2005). There are
two main reasons for the difference in the
estimated number of obesity deaths—newer
data and different methods of analyzing the
data. Because obesity has many different
effects on numerous diseases, doctors have
difficulty reliably identifying obesity-related
deaths based on death certificates. Scientists
are now using more complex modeling techniques to estimate deaths related to obesity.
Regardless, obesity shortens the average
lifespan of an adult by four to nine months,
and in a child, the lifespan may be cut by
two to five years, given the current childhood
obesity rates.
Obesity-attributable medical expenditures
have been estimated to be $117 billion in
the U.S. (Finkelstein, Fiebelkorn, & Wang,
2003). In 2002, the cost difference between
treating a normal-weight person and an
obese individual was $1,244, up from $272
in 1987. In general, the annual medical costs
for overweight and obese individuals (under
the age of 65 years) is 14.5% and 36–37.4%
higher compared to normal-weight individuals, respectively (Segel, 2006). Weight loss
can reduce lifetime medical costs by $2,200
to $5,300 per person.
In the corporate world, the impact can be
significant. The hospital inpatient utilization
rate for workers with unhealthy weights was
143% higher than for normal-weight workers.
In March of 2005, the annual premium for an
employee averaged $6,281.
Since 2000, employment-based health
insurance premiums have risen 73% (The
Henry J. Kaiser Family Foundation, 2005).
Meanwhile, the average employee contribu266
tion to health insurance grew more than
143%, with employees paying $1,094 more
in annual premiums for family coverage
(Smith et al., 2006).
Health Objectives
Given the rising obesity and inactivity
levels and correlating higher healthcare costs,
being proactive in weight-management is
critical. These issues are also being addressed
at a federal level, which could affect corporations and consumers working with LWMCs.
The mission of the Center for Nutrition
Policy and Promotion, an entity within the
U.S. Department of Agriculture (USDA), is
to improve the nutrition and well-being of
Americans. In support of these objectives,
the center offers several core resources,
including the following:
• Dietary Guidelines for Americans
• My Pyramid Food Guidance System
• Healthy Eating Index
• U.S. Food Plans
• Nutrient Content of the U.S. Food Supply
• Expenditures on Children by Families
The USDA Dietary Guidelines are published every five years by the USDA (see
page 160). The guidelines provide educational material on good dietary habits to
promote healthy living and reduce the risk
for developing major chronic diseases for all
Americans (from age two to aging adults).
In 1979, the U.S. Surgeon General established national health objectives that served
as the basis for the development of state and
community health plans (U.S. Department
of Health and Human Services, 2000). The
objectives were developed through a broad
consultation process, derived from current
scientific knowledge, and designed to measure programs over time. Healthy People, the
statement of these national health objectives,
is designed to identify the most significant
preventable threats to health, and to establish a national consensus of how to reduce
them. The current version, Healthy People
2010, contains 467 objectives in 28 focus
areas (U.S. Department of Health and Human
Services, 2000). Under focus area number 19,
entitled “Overweight and Obesity,” specific
objectives include the following:
• Objective 19-1: Increase the proportion
of healthy-weight adults to at least 60%
• Objective 19-2: Reduce the proportion of
obese adults to less than 15%
The National Institutes of Health (NIH) in
2005 developed a strategic plan for obesity
research, earmarking a budget of $440.3 million. The NIH recognizes the multifaceted
variables that affect obesity. Its plan to fight
obesity is organized into four major themes
related to obesity prevention and treatment:
• Lifestyle modification
• Pharmacologic, surgical, or other medical
approaches
• The link between obesity and associated
health conditions
• Crosscutting research topics, including
health disparities and technology
The Food and Drug Administration’s
(FDA) Obesity Working Group released
its final report in 2004 (U.S. FDA, 2004).
The group’s long- and short-term proposals are based on the scientific knowledge
that weight control is primarily a function
of caloric balance. Consequently, the FDA
focuses on calorie counting in its obesity campaign. The FDA’s ongoing actions
include the following:
• Labeling: Enhancing food labels to
display the calorie count more prominently, and implementing more meaningful serving sizes
• Enforcement agencies: Collaborating
with the Federal Trade Commission
(FTC) to increase enforcement against
weight-loss products that have false or
misleading claims, and products that
declare inaccurate serving sizes
• Educational partnerships: Working
cooperatively with other government
agencies, nonprofits, industry, and
academia to educate Americans on the
dangers of obesity and the importance
of leading healthier lives through better nutrition
• Restaurants: Encouraging the restaurant industry to launch a nationwide,
Chapter 12
voluntary, and point-of-sale nutritioninformation campaign for consumers
• Therapeutics: Revising FDA guidance
for developing obesity drugs and
addressing challenges and gaps in
knowledge about existing drug therapies for treating obesity
• Research: Supporting others and collaborating (with others, such as the
NIH) on obesity-related research
Safe and Effective
Weight Loss
L
ifestyle changes, including modifications of food intake and physical activity to establish a daily negative caloric
balance, remain the hallmarks of effective
programming. It can be difficult to accurately
estimate weight-loss rates for clients given
the numerous factors influencing weight
loss. Additionally, using weight-loss rate
is not recommended for long-term weight
management, because of the potential lean
body mass gain that accompanies overload
with resistance training. Instead, it is best to
focus the client’s attention on the perceived
benefits of accomplishing various programrelated goals, such as changes in body shape
and image, and self-efficacy.
Modest and realistic expectations include
achieving an initial 5 to 10% reduction in
body weight, as this range is consistent with
improved overall health benefits, increased
self-efficacy, and improved adherence
[American College of Sports Medicine (ACSM),
2010]. Always follow a prudent plan with a
weight-loss goal that is consistent with the
most current dietary guidelines, unless clients are medically supervised by a licensed
physician or registered dietitian. The 2005
USDA Dietary Guidelines and the 2010 ACSM
guidelines recommend a weekly weight loss
of 0.5 to 1.0 kg (1.1 to 2.2 pounds) per week,
which necessitates a negative caloric balance
of 3,850 to 7,700 kcal weekly, or 550 to 1,100
kcal daily. A more conservative approach of
0.5 to 1.0 pounds (0.23 to 0.45 kg) per week,
267
Chapter 12 necessitating a negative caloric balance of
1,750 to 3,500 kcal weekly, or 250 to 500 kcal
daily, may be more suitable for some clients.
Ultimately, the weight-loss goal must be safe,
satisfy the needs and desires of the client,
and include the following considerations:
• Age
• Target weight (or amount of
weight to be lost)
• Current physical-activity level
• Medical concerns
• History of dieting
• Emotional and psychological state
Individuals do not need to lose weight if
their weight is within the healthy range represented in Table 12-2, if they have gained
less than 10 pounds since reaching their
adult height, or are otherwise healthy (USDA,
Table 12-2
Healthy Weight Ranges for Men and Women
Height
Weight (pounds)
Weight (kg)
4'10" (1.47 m)
91–119
41.4–54.1
4'11" (1.50 m)
94–124
42.7–56.4
5'0" (1.52 m)
97–128
44.1–58.2
5'1" (1.55 m)
101–132
45.9–60.0
5'2" (1.57 m)
104–137
47.2–62.2
5'3" (1.60 m)
107–141
48.6–64.1
5'4" (1.62 m)
111–146
50.5–66.4
5'5" (1.65 m)
114–150
51.8–68.2
5'6" (1.67 m)
118–155
53.6–70.5
5'7" (1.70m)
121–160
55.0–72.7
5'8" (1.73 m)
125–164
56.8–74.5
5'9" (1.75 m)
129–169
58.6–76.8
5'10" (1.77 m)
132–174
60.0–79.1
5'11" (1.80 m)
136–179
61.8–81.4
6'0" (1.83 m)
140–184
63.6–83.6
6'1" (1.85 m)
144–189
65.5–85.9
6'2" (1.87 m)
148–195
67.3–88.6
6'3" (1.90 m)
152–200
69.1–90.1
6'4" (1.93 m)
156–205
70.9–93.2
6'5" (1.95 m)
160–211
72.7–95.9
6'6" (1.98 m )
164–216
74.5–98.2
Source: United States Department of Agriculture (2005). USDA Dietary
Guidelines for Americans. www.health.gov/dietaryguidelines.
268
2005). Weight losses of only 5 to 10% may
greatly diminish any health concerns associated with being overweight, but even smaller
losses can make a difference. Weights above
the ranges shown in Table 12-2 are considered
less healthy for most people. The greater the
margin of difference between actual body
weight and the healthy weight range for
height, the higher the risk of weight-related
health disorders.
A more useful estimate of quantifying a
healthy weight in relation to height can be
obtained by calculating a height-normalized
weight index. The body mass index (BMI)
is the most commonly used indicator (Table
12–3). While the BMI has limited applications
for athletes, seniors, and children, research
points to a strong relationship between BMI
and mortality rates. In a research study following 1 million adults for 14 years, the
lowest BMI-mortality rates were BMI scores
between 23.5 and 24.9 for men and 23.0 and
23.4 for women.
Understanding
Behavioral Change
P
eople make choices and decisions based
on how they feel and think (Figure
12-1). Everyone’s belief system is based
on past and present experiences. These belief
systems drive people’s thought processes and
feelings, and the decisions and choices they
make. To influence desired behaviors, LWMCs
must work with clients to help them think
about ways to achieve desirable behaviors and
talk to them about their feelings about those
desired behaviors. LWMCs may successfully
alter unfounded belief systems to influence
decisions and choices. Additionally, these
experiences should be engaging, positive, and
memorable, and build self-efficacy to empower clients to want to stop unhealthy behaviors, while also enhancing their confidence in
their abilities to initiate change.
Using a weight-management example to
illustrate this point, imagine a client with
an estimated caloric intake of 2,000 kcal,
Chapter 12
Table 12-3
Body Mass Index
Height (inches)
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
19
20
21
22
23
91
94
97
100
104
107
110
114
117
121
125
128
132
136
140
144
148
152
156
95
99
102
106
109
113
116
120
124
127
131
135
139
143
147
151
155
160
164
100
104
107
111
115
118
122
126
130
134
138
142
146
150
155
159
163
168
172
105
109
112
116
120
124
128
132
136
140
144
149
153
157
162
166
171
176
180
110
114
118
121
125
130
134
138
142
147
151
155
160
165
169
174
179
184
189
24
25
26
Weight (pounds)
115 119 124
119 124 128
123 128 133
127 132 137
131 136 142
135 141 146
140 145 151
144 150 156
148 155 161
153 159 166
158 164 171
162 169 176
167 174 181
172 179 186
177 184 191
182 189 197
187 194 202
192 200 208
197 205 213
27
28
29
30
35
40
129
133
138
143
147
152
157
162
167
172
177
182
188
193
199
204
210
216
221
134
138
143
148
153
158
163
168
173
178
184
189
195
200
206
212
218
224
230
138
143
148
153
158
163
169
174
179
185
190
196
202
207
213
219
225
232
238
143
148
153
158
164
169
174
180
185
191
197
203
209
215
221
227
233
240
246
167
173
179
185
191
197
203
210
216
223
230
237
243
250
258
265
272
279
287
191
198
204
211
218
225
233
240
247
255
263
270
278
286
294
303
311
319
328
Note: Find your client’s height in the far left column and move across the row to the weight that is closest to the client’s weight. His or her body mass index will be at the top of that column.
}
Subconscious
who would like to lose 1 pound (0.45 kg) per
week. Long-term weight-loss success typically involves modest caloric reductions of 10
to 15% initially, although some studies do
demonstrate long-term success with initial
caloric reductions of 20 to 25%. Using a modest reduction of 300 kcal of intake leaves a
balance of 200 kcal that must be expended via
physical activity and exercise. Most overweight
Figure 12-1
}
Influences on
decisions and
choices
Conscious
clients tend to be deconditioned and are better suited to walking or performing walk-jog
intervals for exercise that burns between 5 and
9 kcal per minute (for a 165-pound or 75-kg
individual). To expend 200 kcal, the individual
needs to participate in 23 minutes of jogging or 40 minutes of walking. Considering
that only 46% of the U.S adult population
meets minimum recommendations of the
269
U.S Surgeon General, 38% participate in 10
to 30 minutes of physical activity, and 16%
participate in less than 10 minutes of physical activity daily, the likelihood of success in
expending 200 kcal is low. More importantly,
the individual may potentially have a negative
and unenjoyable experience that might prove
to be disengaging. Remember that the initial
few weeks of a program have a high risk of
dropout. A viable option may be to increase
daily physical activity levels to expend 75 to
100 kcal, leaving the balance to structured
exercise, but keep in mind that too many
lifestyle changes may negatively impact longterm adherence. Consider the following strategy to enhance the overall experience, engage
the individual, and promote self-efficacy:
• F ocus the initial two to four weeks
on building self-efficacy and program
compliance and creating an enjoyable
experience.
• De-emphasize numbers temporarily until
attitudes toward regular exercise and
activity appear positive and the desired
behaviors occur frequently with minimal
resistance.
Transtheoretical Model
of Change (Stages of
Behavioral Change)
T
his model was developed as a framework
to describe the different stages of acquiring and maintaining healthy behavior.
It provides a premise to understand lifestyle
modification based upon readiness for change,
making the assumption that people progress
through stages of behavioral change at varying rates (Prochaska & Marcus, 1994). To
adopt or engage in new behaviors, individuals must first move in an orderly progression
through a number of stages. The model also
takes into account that lapses are inevitable
and part of the process of working toward
lifelong change. Hence, it is possible for an
individual to move in either direction along
this continuum. The four components of this
270
model, which are constructs hypothesized to
influence behavior, are as follows:
• Stages of change
• Processes of change
• Decisional balance
• Self-efficacy
Stages of Change
There are five stages of change described
in the transtheoretical model (Table 12-4 and
Figure 12-2):
Precontemplation:
• The individual has no plans or thoughts
to improve or change behavior within
the next six months.
• The individual is neither engaged in
change, nor contemplating it.
• The individual may have lapsed or is
in denial at this level. He or she is
resigned to the unhealthy behavior
because of previous failed efforts and no
longer believes that he or she can control
change.
Contemplation:
• The individual is somewhat ambivalent
toward changing behavior and weighs
the costs and benefits of making the lifestyle modification.
• The individual is not engaged, but is
contemplating improving or changing
behavior within the next six months
(“thinking about it”).
• Low self-efficacy levels increase the resistance to changing behavior.
Preparation:
• The individual has taken some steps
toward healthier behavior and intends to
commit within the next 30 days, or has
already begun to make some changes,
but demonstrates inconsistent behavior (irregular activity patterns). There
is, however, greater determination to
achieve change.
• The individual is mentally and physically preparing and may ask questions,
seek information, or make purchases
(of equipment, etc.) as an incentive
to commit.
Chapter 12
Table 12-4
The Stages of Behavior Change
Stage
Traits
Precontemplation Unaware or under-aware of
the problem, or believe that
it cannot be solved (e.g.,
latent pain)
Contemplation
Aware of the problem and
weighing the benefits
versus risks of change
Goals
Strategies
Increase awareness of the
Validate lack of readiness to change and clarify that this
risks of inactivity, and of the decision is theirs
benefits of activity
Encourage reevaluation of current behavior and self-exploration,
Focus on addressing
while not taking action
something relevant to them Explain and personalize the inherent risks
Have them start thinking
about change
Utilize general sources, including media, Internet, and
brochures to increase awareness
Inform them of available
options
Validate lack of readiness to change and clarify that this
decision is theirs
Provide cues to action and
Have little understanding of some basic structured
how to go about changing
direction
Encourage evaluation of the pros and cons of making change
Identify and promote new, positive outcome expectations and
boost self-confidence
Offer invitations to become more active (e.g., free trials)
Preparation
Action
Seeking opportunities
to participate in activity
(combine intent and
behavior with activity)
Structured, regular
programming with frequent
positive feedback and
reinforcements on their
progress
Verify that the individual has the underlying skills for behavior
change and encourage small steps toward building self-efficacy
Desire for opportunities to
maintain activities
Establish exercise as a
habit through motivation
and adherence to the
desired behavior
Behavior-modification strategies
Changing beliefs and
attitudes
High risk for lapses or
returns to undesirable
behavior
Maintenance
Empowered, but desire
a means to maintain
adherence
Identify and assist with problem-solving obstacles
Help the client identify social support and establish goals
Focus on restructuring cues and social support toward building
long-term change
Increase awareness to inevitable lapses and bolster selfefficacy in coping with lapses
Reiterate long-term benefits of adherence
Require continual feedback on progress
Maintain support systems
Reevaluate strategies currently in effect
Maintain interest and avoid
boredom or burnout
Plan for contingencies with support systems, although this may
no longer be needed
Good capability to deal
with lapses
R einforce the need for a transition from external to internal
rewards
Plan for potential lapses
Encourage program variety
Lapse
Encounter lapses that they
are unable to overcome
Return to action
Identify reasons for lapse
Identify current stage of change to progress once again toward
action
aintain existing systems and relationships and offer
M
appropriate support
271
Figure 12-2
The stages
of behavioral
change
*
*
*
*
* When adopting healthy behaviors, termination represents the
complete adoption of behavioral traits of a particular stage
and readiness to move forward to the next stage.
Action:
• The individual has shown improved
behavior, and has been participating in
regular activity for less than six months.
• The individual demonstrates the desire
to change his or her beliefs and attitudes, and should be supported as
much as possible.
• The individual is still considered to be at
a high risk for relapse.
Maintenance:
• Practices have been sustained for more
than six months. The person demonstrates adherence and higher levels of
self-efficacy.
• The individual has successfully developed strategies to cope with lapses.
• Discouragement with occasional slips or
lapses may hamper maintenance within
this phase and result in the individual
reversing into unhealthy behaviors. A
typical pattern involves cycling through
the stages of change several times before
272
the change becomes truly established as
a lifelong endeavor.
Individuals progress through these stages
at different rates, sometimes remaining in
one stage or relapsing to earlier stages for
extended periods of time. Never assume
that someone is in the action stage because
he or she joined a club or fitness center or
purchased personal-training sessions. LWMCs
must identify the stage of change before
starting to plan programs and then implement appropriate strategies to move a client
toward the action phase. For example, a new
member might be offered an orientation
with a basic personal-fitness plan and receive
instructions on using equipment. While this
may be appropriate for an individual in the
action stage, LWMCs may need to adopt a different strategy for an individual in the contemplation stage. Such an individual may
require education on the benefits of lifestyle
change, diet, and physical activity.
After successfully developing a rapport
so that a client feels comfortable opening
up, LWMCs should assess the client’s readiness to change a negative behavior. During
the initial interviews, LWMCs should ask
the following questions to assess a client’s
readiness for change:
• Are you making the decision to change a
behavior for yourself?
• Will your friends, family, or loved ones
support you in this endeavor?
• Besides possible health improvements,
what other reasons do you have for
wanting to change this behavior?
• Do you believe that you are susceptible
to injury or illness, or that you may
compromise your health by continuing
your current behavior?
• Are you willing to make the commitment to this change, even through very
tough and challenging times?
• Are you willing to make the desired
change a top priority?
• Have you ever tried to change this or a
similar behavior before?
• Are you committed to being patient with
yourself and persistent when and if you
encounter obstacles?
The more “yes” answers the client provides,
the more ready he or she is to make the commitment to change. A client who answers “no”
to most questions, by contrast, is less likely to
make the commitment and adhere to a program. LWMCs should identify the current stage
and develop appropriate strategies to move
the client toward the action stage.
Processes of Change
Individuals use certain strategies as they
move between stages. These strategies are
divided into cognitive (or experiential) and
behavioral categories:
• Cognitive processes (CP) are defined as
those that gather relevant information
on the basis of one’s own experiences.
• Behavioral processes (BP) are defined as
those that gather relevant information
via events from the environmental and
experienced behaviors.
Some examples of the processes of change
include the following:
• Consciousness raising is the act of
increasing knowledge and awareness of
healthy behaviors.
• Helping relationships feature caring and
understanding, and include gaining the
trust and acceptance of others as the
individual assumes healthy behaviors.
• Counter-conditioning is the act of changing one’s response to a particular stimulus
with the objective of substituting healthy
behaviors for unhealthy ones.
• Stimulus control is the act of changing one’s environment by removing
cues that trigger unhealthy behaviors
and adding prompts to entice healthier
alternatives.
• Social liberation is the act of increasing
social opportunities to make healthy
choices.
• Self-evaluation is the act of assessing or
critically reviewing one’s image and performance after engaging in unhealthy
and healthy behaviors.
Chapter 12
• Environmental evaluation is the act of
assessing what effect unhealthy behavior may have on one’s own environment.
• Self-liberation is the belief that a person
has to change his or her life from within
and is driven by self-efficacy.
• Dramatic relief is the act of experiencing negative emotions associated with
engaging in unhealthy behavior.
Within each stage, individuals can and will
utilize various processes of change to move
toward the next stage. Transitions between
stages can be facilitated with stage-specific
interventions. For example, during the precontemplation stage, consciousness-raising
is an effective process. During the action
stage, self-liberation, stimulus control, and
helping relationships are effective processes.
Decisional Balance
Decisional balance is the third component
of this model. It assumes that decisionmaking regarding healthier behavior involves
weighing the risks and benefits of changing
behavior (i.e., measuring the benefits to be
attained against the potential losses involved
with making the change) (Table 12-5).
Differences exist among the individual stages
with regard to benefit–risk analysis and subsequently, individuals’ likelihood to change.
During the precontemplation and contemplation stages, individuals typically perceive
more risks than benefits regarding change,
and therefore remain resistant or ambivalent.
During the preparation stage, the benefits
and risks appear equal, which explains why
individuals are often stuck in this stage.
During the action and maintenance stages,
the benefits outweigh the risks, and therefore, the individual continues to move toward
desired behaviors. LWMCs should attempt to
shift the decisional balance and influence the
client’s perceptions of the potential benefits
vs. risks (e.g., diffuse anxieties and irrational
beliefs) without being confrontational.
Self-efficacy
Self-efficacy is defined as the belief in
one’s capability to complete a task. Like
self-confidence, this terms deals with a belief
273
Instructions:
• Work with the client to document the gains and potential losses that he or she might experience when making a
lifestyle change.
• Identify and list the recommended implementation strategies needed to achieve the gains and list coping strategies that
can be used to deal with the potential losses or obstacles associated with the change.
Decisional Balance WorksheeT
Perceived gains associated with Perceived losses associated with
adopting desired behaviors adopting desired behaviors
1.________________________________________1.______________________________________
2.________________________________________2.______________________________________
3.________________________________________3.______________________________________
4.________________________________________4.______________________________________
Strategies to maximize Strategies to minimize
potential for achieving gains
potential of perceived losses
1.________________________________________1.______________________________________
2.________________________________________2.______________________________________
3.________________________________________3.______________________________________
4.________________________________________4.______________________________________
in one’s self. While self-confidence is more
global, self-efficacy is more task-specific, and
is influenced by the following:
• Past performance and experiences
(successes and failures, and the
experience itself)
• Vicarious experiences (successes and
failures of others who are similar to the
individual and are seen as role models)
• Verbal persuasion (support offered by
others—credible sources—that build
trust and rapport)
• Physiological responses (responses of
heart rate, sweat rate, ratings of perceived exertion, etc., and the perception of these responses as positive or
negative)
• Emotional responses (the feelings and
impressions associated with the task,
both positive and negative)
• Imagery experiences (the experience one
envisions, both positive or negative)
The more capable a person feels regarding his or her ability to engage in a task
274
and successfully accomplish it, the more
likely he or she is to adhere. Improvements
in self-efficacy occur naturally as a person
progresses through the stages. The level of
self-efficacy is lowest in the earlier stages
of behavioral change. Establishing challenging, but manageable, tasks is an effective strategy in building self-efficacy.
Self-efficacy will influence task choice or
complexity. Individuals with lower levels of
self-efficacy tend to select easier tasks to
ensure success or difficult tasks to ensure
failure. Individuals with higher levels of
self-efficacy typically select appropriate
task complexities. Self-efficacy also influences effort. People with lower levels will
put forth minimal effort, as they have a
higher perception of failure. Self-efficacy
will also influence persistence. Those with
higher levels of self-efficacy tend to persevere in spite of obstacles or minor setbacks.
Finally, self-efficacy can be a determinant
as well as an outcome of activity. Success
in accomplishing a task or successfully
performing an activity raises self-efficacy
levels. Therefore, working to improve a
client’s self-efficacy level will improve the
probability of achieving a desired behavior.
Tracking Progress and
Keeping Records
E
ffective goal-setting will improve adherence and performance. Goals clarify
expectations and provide feedback, and
are a means to evaluate progress. If appropriately set, they establish appropriate challenges for individuals to strive for, which in
turn improves self-efficacy and confidence.
Additionally, effective goals can focus the
client’s attention more intently and motivate
the client to take action. Establishing goals
is the basis and justification for maintaining participation and activity logs. Logs are
discussed in the next section of this chapter,
while goal-setting strategies are discussed in
Chapter 13.
Participation and Activity Logs
LWMCs can empower clients to have more
self-control and self-management, and create
a need within clients to assume more responsibility for making a lifestyle change. One
simple technique to achieve these objectives
involves maintaining activity or participation logs, a responsibility that the LWMC
should share with the client. Keeping activity
records and logs of the measurable programming parameters provides the following:
• A means to evaluate program adherence
and efficacy
• Information for program progression,
modification, and continued education
• Effective feedback for clients
Record-keeping is an invaluable component of a client’s weight-management
program, especially during the first six
months, when the individual is considered
at high risk for noncompliance and prone to
dropout. It is best to record some data after
workout sessions or meals (e.g., heart rates,
sets and repetitions, meal composition),
while other information needs to be tracked
Chapter 12
over a longer period of time (e.g., changes
in behavior, attitudes). Compliance with
maintaining records is contingent upon convenience; the more accessible and simplistic
the modality, the more likely the client is to
comply. Given the widespread advances in
technology and portability in communications, LWMCs should determine the medium
that suits each client’s lifestyle. Simple log
forms and diaries can be created electronically or in the traditional paper-and-pencil
format. Textbooks and health clubs typically offer numerous examples of such templates. They may also be created by LWMCs
to suit the specific needs of their clients.
Activity logs can be created to use a variety
of formats for recording events, ranging
from simply recording the completion of
an event to earning points or mileage for
activities or events that accumulate toward
an end goal or reward. Ultimately, LWMCs
and their clients should agree on a format
that facilitates the achievement of specific
goals and lifestyle changes. Figure 12-3 is
an example of an activity log that utilizes a
points system.
Emotional Association
With Programming
Any positive emotional change associated with the client’s program can be
leveraged for adherence-support purposes.
Strategic use of the positive emotional feelings associated with activity will promote
a client’s continued desire to participate.
Normally, a client will experience a positive mood change after just a few weeks
or months of regular activity. This results
from changes in circulating endorphins,
serotonin and norepinephrine levels, or
the increased self-efficacy that comes from
accomplishing tasks or achieving some
initial short-term goals. Arm clients with
the knowledge that continued exercise and
activity will likely benefit their stress levels, energy levels, moods, and feelings of
self-worth and self-efficacy, in addition to
bringing about positive physical changes.
Leverage emotional change by recommending exercise types, amounts, and
275
Figure 12-3
Example of an
activity log that
utilizes a points
system
Goal:____________________________________________________________________
Log Instructions: Complete this electronic log daily and award yourself points as
follows:
• Every 10 minutes of continuous moderate-intensity activity = 2 points
• Every 10 minutes of incremental or less-than-moderate-intensity activity = 1 point
• Every flight of stairs substituted for an elevator or escalator = 1 point
• Submitting your weekly totals to your trainer = 1 point
Week 1
Week 2
Week 3
Week 4
Week 5
Week 6
Points: Points: Points: Points: Points: Points:
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Total Points
____________________________________
Points: Points: Points: Points: Points:
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
intensities that promote positive aftersession feelings. A slow start with moderate
progression ensures positive after-session
feelings that promote long-term maintenance. However, it is prudent that LWMCs
always investigate a client’s aversion to
physical stress and discomfort prior to
implementing this strategy.
An effective means to evaluate emotional
change is through verbal or documented
feedback from the client. This allows LWMCs
276
Points: L if estyle & W eigh t Man agem en t Coach Manual
to assess the emotional perceptions of the
recently completed activity.
The exercise-induced feeling inventory
(EFI) is a survey administered after an exercise or activity session that seeks to identify the individual’s after-session impressions
(Gauvin & Rejeski, 1993) (Figure 12-4). The
use of such an inventory can facilitate the
establishment of baseline emotional states
and opinions regarding previous exercise
experiences when administered prior to
activity in the new program. Additionally, it
Chapter 12
Figure 12-4
Instructions: Please use the following scale to indicate the
extent to which each word describes how you feel at this
moment in time. Record your responses by checking the
appropriate box next to each word.
0 = Do not feel
1 = Feel slightly
2 = Feel moderately
3 = Feel strongly
4 = Feel very strongly
0
1
2
3
4
1. Refreshed
q
q
q
q
q
2. Calm
q
q
q
q
q
3. Fatigued
q
q
q
q
q
4. Enthusiastic
q
q
q
q
q
5. Relaxed
q
q
q
q
q
6. Energetic
q
q
q
q
q
7. Happy
q
q
q
q
q
8. Tired
q
q
q
q
q
9. Revived
q
q
q
q
q
10. Peaceful
q
q
q
q
q
11. Worn out
q
q
q
q
q
12. Upbeat
q
q
q
q
q
Exercise-induced
feeling inventory (EFI)
survey
Reprinted with permission from Gauvin, L. & Rejeski, W.J. (1993). The exercise-induced feeling inventory:
Development and initial validation. Journal of Sport & Exercise Psychology, 15, 4, 409.
provides a means to track emotional change
and offers valuable feedback to evaluate the
program design. The information collected
over time can be effectively used as a tool
to empower clients into self-direction as
the LWMC works to wean them toward selfsufficiency and independence.
During the interview or informationgathering stage with a client, consider
administering the survey while discussing
previous experiences and preferences, which
will help to establish an emotional baseline.
During the initial stages of working with a
new client or any time significant changes
are made to a program, LWMCs should
administer the survey with some frequency.
However, it is important to taper the frequency within a few weeks to minimize the
chances of desensitization and maintain the
learning effects associated with the survey.
The key objective of collecting aggregated data is to track changes over time
by monitoring whether there is an upward
trend of positive subscales or a downward
trend of negative subscales. This information
provides insight into long-term adherence
to programming and efficacy of a particular
program design. The culled information can
also be compiled and presented in a graphic
format to illustrate changes to clients. Figure
12-5 shows a graphic representation of aggregated scores on the EFI over a 12-week period.
Strategies for
Overcoming Obstacles
Barriers to Participation
Of new and returning exercisers, 50 to
65% will cease their activity within three
to six months, although it is estimated that
working with personal trainers can increase
adherence by 40% over a 24-week period
(Annesi, 2000; Pronk et al., 1994). Clients
often have a history of unsuccessful weight
loss or temporary weight-loss success.
These perceived failures certainly present
277
Chapter 12 Figure 12-5
Examples of aggregated data for subscales of positive
engagement and
physical exhaustion
over 12 weeks
12
Profile of Moods Value:
Positive Engagement
11
12
11
10
10
9
9
8
8
7
7
6
6
5
5
4
4
1
4
8
Week
12
themselves as barriers to future success.
It is the responsibility of LWMCs to diffuse
clients’ anxieties and discuss existing belief
systems. Many clients, based on experience,
have unfounded beliefs and misconceptions regarding foods, physical activity, and
dietary practices. While LWMCs must never
devalue a client’s belief systems, the goal
is to identify misconceptions without being
insensitive.
Obstacles to participation and long-term
adherence are inevitable and should be
acknowledged. These potential barriers are
considered high-risk situations and can challenge the client’s confidence in adhering to
the desired behavior (Buckworth & Dishman,
2002). They most often occur during the
action stage of change. Consequently, LWMCs
must increase the clients’ awareness of this
likelihood and work with them to achieve the
following four objectives:
• Recognize that lapses are inevitable
• Restructure the perception of lapses
(as slips instead of failures)
• Identify barriers or sources of potential
lapses
• Anticipate barriers and potential lapses,
and develop effective coping strategies
278
Profile of Moods Value:
Physical Exhaustion
1
4
8
Week
12
Appropriate coping strategies lead to
increased self-efficacy and a decreased probability of a relapse. Inappropriate coping
strategies, or the absence of any coping
strategies, will decrease self-efficacy, as well
as the positive expectations regarding adherence. Figure 12-6 provides an example of a
worksheet that LWMCs can use to help identify high-risk situations and document coping
strategies to circumvent barriers. Barriers
manifest themselves as a product of environment and lifestyle. They may also appear due
to an internal process (Griffin, 2006). These
environment and lifestyle factors are called
external barriers and include:
• Lack of convenience
• Financial limitations
• Increased work demands
• Increased family demands
• Lack of support
• Inclement weather
• Injury or medical issues
• Overtraining
• Lack of time
• Lack of interest in programs (boredom)
• Lack of available childcare
• Lack of transportation
• Unrealistic goals
Figure 12-6
Indicate which of the following obstacles deter you from participation:
q Busy work schedule
q Lack of convenience q Lack of activity partner(s)
q Scheduling conflict with partner
q Scheduling conflict with activities
q Unrealistic goals
q Physical injury
q Busy home/family schedule
q Lack of available childcare
q Insufficient activities or amenities
q Lack of self-motivation
q Lost interest in keeping records
q Goals too challenging
q Health concerns/problems
Chapter 12
q Gym/club environment
q Financial constraints
q Lack of support
q Lack of confidence in my ability
q Failure to reach goals
q Inclement weather
q Other _____________________
Worksheet:
High-risk
situations and
effective coping strategies
For each identified obstacle, devise a primary coping strategy to overcome the obstacle. In the event that your
primary coping strategy may not prove successful, consider an alternative plan of action.
Obstacle
Primary Coping Strategy
Secondary Coping Strategy
q
q
q
q
q
q
q
• Educational, socioeconomic, and cultural
issues
Internal barriers are personal thoughts,
perceptions, and feelings that individuals
have about themselves, or about the exercise
program itself, that reduce adherence. These
barriers may include:
• Anxieties regarding one’s physique or the
perception of one’s physique by others
• Intimidation in the gym environment
• Self-esteem
• Self-efficacy
Relapse Prevention
The major challenge of weight maintenance is to avoid regaining lost fat. The limited follow-up data on weight-loss programs
indicate low (3 to 6% of initial weight) to
no sustained levels of weight loss after four
to five years. A successful program is often
defined as maintaining fat losses of at least
5% of body weight (Anderson et al., 2001).
The National Weight Control Registry
is the largest prospective investigation of
long-term successful weight-loss maintenance. It monitors individuals who have
lost at least 30 pounds (13.6 kg) and sustained the loss for a minimum of one year,
although registrants often have achieved
greater losses and sustained the losses for
more than five years. A majority of the success stories within the registry attribute
ongoing maintenance
to reduced-calorie and low-fat diets and
increased levels of physical activity. While
it has not been established whether these
behaviors represent minimal competence
for weight-loss maintenance, these modifications have produced successful long-term
weight-loss maintenance.
Textbooks present models to explain the
environmental, emotional, and behavioral
aspects of relapse. Still, researchers do not
fully understand the biological impact of
metabolic rate, hunger, and satiety, which
are all factors contributing to regained
weight. Therefore, LWMCs should continue to:
• Address the risks of relapse as part of
the overall program
• Exert leadership in combating weightmanagement relapse
279
• Emphasize long-term change as the
overall lifestyle goal
• Educate clients that regained weight
is not a failure, but rather an indicator
to start another phase of active
management
A more systematic approach, assuming
the LWMC first identified high-risk situations and developed appropriate coping
strategies, is to:
• Teach the client that temporary
breaks or slips from regular activity
are acceptable and should not to be
viewed as failures. If these relapses
are anticipated or structured, a client should look at such incidents as
deserved or programmed breaks.
• Identify in which stage of change the
relapse occurred in the past
• Identify potential new barriers or obstacles, and evaluate why previous coping
strategies, if any, were not effective for
clients
• Develop new coping strategies in anticipation of future barriers
• Identify the most effective start-up
strategies to initiate a return to an
activity that is appropriate given the
current stage of change
• Inquire about strategies that have proven successful before moving to
the action phase
280
Summary
A
s the number of overweight and obese
individuals grows, the need for qualified Lifestyle & Weight Management
Coaches becomes more critical. Success as
an LWMC requires knowledge and skills
sets to address the three primary tenets of
weight management: lifestyle and behavior
modification; regular exercise; and sound
nutritional programming. LWMCs must
identify, understand, and develop programs
around the intricate complexities of weight
management. They need to demonstrate
competency with behavioral change; implement effective strategies to facilitate the
adoption of healthier behaviors; design and
implement safe and effective exercise and
dietary programs consistent with client
goals; instill the philosophy of client ownership with this lifelong endeavor; recognize
potential obstacles to success and develop
coping strategies to overcome such barriers;
and leverage all opportunities to associate
positive emotion and thinking to the exercise experience. This involves a multifaceted approach with the three components,
working independently with clients or as
part of a team of health professionals while
respecting scope of practice.
References
American College of Sports Medicine (2010).
Guidelines for Exercise Testing and Prescription
(8th ed.). Philadelphia: Wolters Kluwer/Lippincott,
Williams & Wilkins.
Anderson, J.W. et al. (2001). Long-term weightloss maintenance: A meta-analysis of U.S. studies.
American Journal of Clinical Nutrition, 74, 579–584.
Annesi, J. (2000, July-August). Retention crisis?
Exercise dropouts and adherents. Fitness Business
Canada, pp. 6–8.
Buckworth, J. & Dishman, J.K. (2002). Exercise
Psychology. Champaign, Ill.: Human Kinetics.
Finkelstein, E.A., Fiebelkorn, I.C., & Wang, G. (2003).
National medical spending attributable to overweight
and obesity: How much, and who’s paying? Health
Affairs Web Exclusive, W3, 219–226.
Gauvin, L. & Rejeski, W.J. (1993). The exerciseinduced feeling inventory: Development and initial
validation. Journal of Sport and Exercise, 15,
403–423.
Griffin, J.C. (2006). Client Centered Exercise
Prescription (2nd ed.). Champaign, Ill., Human
Kinetics.
Marketdata Enterprises, Inc. (2007). The U.S.
Weight Loss & Diet Control Market (9th ed.).
www.marketdataenterprises.com.
Mokdad, A. et al. (2005). Correction: Actual causes
of death in the United States, 2000 (letter). Journal
of the American Medical Association, 293, 3, 293–
294 (correction of original study).
Mokdad, A. et al. (2004). Actual causes of death in
the United States. Journal of the American Medical
Association, 291, 1238–1245 (original study).
Prochaska, J.O. & Marcus, B.H. (1994). The
transtheoretical model: Applications to exercise.
In: Dishman, R.K. (Ed.) Advances in Exercise
Adherence. Champaign, Ill.: Human Kinetics.
Chapter 12
Pronk, N. et al. (1994). Effects of Increased stimulus
control for exercise through use of a personal
trainer. Annals of Behavioral Medicine, 16: SO77.
Segel, J.E. (2006). Cost of Illness Studies—A
Primer. RTI International.
Smith, C. et al. (2006). Health spending growth
slows in 2004. Health Affairs, 25, 1, 186–196.
The Henry J. Kaiser Family Foundation (2005).
Employee Health Benefits: 2005 Annual Survey.
United States Department of Agriculture (2005).
USDA Dietary Guidelines for Americans. www.
health.gov/dietaryguidelines
U.S. Department of Health and Human Services
(2000). Healthy People 2010: Understanding
and Improving Health. Washington, D.C.: U.S.
Department of Health and Human Services,
Government Printing Office.
United States Food and Drug Administration
(12 March 2004). Calories Count: Report of the
Working Group on Obesity. www.cfsan.fda.
gov/~dms/owg-rpt.html.
Suggested Reading
Annesi, J. (August, 2001). Using emotions to
empower members for long-term exercise success.
Fitness Management.
Borger, C., et al. (2006). Health spending projections
through 2015: Changes on the horizon. Health
Affairs Web Exclusive, W61: 22 February 2006.
Canadian Society of Exercise Physiologists (2003).
Canadian Physical Activity, Fitness and Lifestyle
Appraisal: CSEP’s Plan for Healthy Active Living.
Food and Drug Administration (2004). Report of the
Working Group on Obesity.
Van Gaal L.F. (1998). Dietary treatment of obesity.
In: Bray G.A., Bouchard, C., & James, W.P.T. (Eds.).
Handbook of Obesity. New York: Marcel Dekker.
281
Len Kravitz
Len Kravitz, Ph.D., is an associate professor and the program
coordinator of exercise science at the University of New Mexico,
where he recently won the Outstanding Teacher of the Year award.
Kravitz was honored with the 1999 Canadian Fitness Professional
International Presenter of the Year and the 2006 Canadian Fitness
Professional Specialty Presenter of the Year awards, as well as
being named the ACE 2006 Fitness Educator of the Year.
Chapter 13
Exercise
Programming
A
ll types of exercise, health, and weight-management
programs need to begin with a goal-setting process. An
invaluable way to manage the action steps in any behav-
ioral- change process is to use the SMART goal-setting approach,
which stands for specific, measurable, attainable, relevant,
and time-bound. Each one of these components is an essential
aspect of goal formation.
SMART Goal Setting
T
he SMART goal-setting system is an effective self-check
tool for developing focused goals for clients. Many goals
in resistance exercise, for example, are associated with
improvements in muscular strength, muscular endurance, power,
balance, speed, and body composition. Goals in cardiovascular
exercise are often related to improvements in health, cardiorespiratory fitness, weight management, and body composition.
Goals for some older clients may be associated with improving
locomotion capabilities, balance, fall prevention, and muscle
mass. The SMART goal-setting structure makes it easy to identify
the correct action steps for developing a person’s health, fitness,
and weight-management plan for success.
IN THIS CHAPTER:
SMART Goal Setting
Specific
Measurable
Attainable
Relevant
Time-bound
Using Health Screening and
Assessment Data
The Physical Activity Readiness
Questionnaire (PAR-Q)
Identification of Signs and
Symptoms of Disease, if Present
Evaluation of the Coronary Risk Profile
Classification of Heart
Disease Risk Factors
Programming Components
Cardiorespiratory Endurance
Muscular Strength and Endurance
Flexibility
Body Composition
Mind/Body Vitality
Cardiorespiratory Training
Step Aerobics
Mixed-impact Aerobics
Mixed Martial Arts Exercise
Indoor Cycling
Aquatic Fitness
Aerobic Interval Training
Resistance Training
Periodization
Circuit Training
Lifestyle Fitness Activities
The SPORT Principle
Specificity
Progression
Overload
Reversibility
Training Effect
Functional Exercise Progression
Exercise Precautions and Modifications
General Precautions
Concerns for Exercising Outdoors
or in Hot Environments
Precautions for Special
Populations and Older Adults
Signs of Stroke or Heart Attack
Summary
Chapter 13 Exercise Programming
Specific
Time-bound
The specificity of goal-setting involves
answering most of the following questions.
• Why is this goal being created? Are
there any benefits to accomplishing
this goal?
• Who is involved in this goal? Does this
goal involve one or more participants?
• What needs to be accomplished? What
outcome or steps to the eventual outcome are desired?
• Where will the goal be accomplished?
Is this a goal that needs to be completed at a gym, at home, at work, or
throughout one’s daily activities?
When will the goal be accomplished?
A schedule needs to be developed to put
the overall goal and the incremental steps
in attaining the goal into an appropriate
timetable.
Measurable
As a person progresses in a goal behavior, there needs to be continual objective measurement to track progress. This
measurement procedure will help evaluate
whether a person is on track in attaining
a specific goal, and will also indicate if
modifications are needed for the goal to be
reached.
Attainable
In the process of goal attainment, it
is helpful to evaluate the necessary steps
to achieve the goal. Thus, a person needs
to assess his or her abilities, skills, and
attitudes toward a particular outcome and
truly determine if this goal is within reach.
If a goal is realistic, a person will be able
and willing to strive toward its accomplishment. Therefore, if a person “believes” that
he or she can attain the goal, the motivation, drive, and perseverance to attain the
goal will be available. It often helps to
draw on past successes with goal-setting
as a means of motivating an individual to
work toward a new goal.
Relevant
Relevant goals are pertinent to the
unique needs, interests, and abilities of the
individual. If a goal is relevant, the individual will be motivated to strive toward
its achievement.
284
Using Health Screening
and Assessment Data
F
or most people, physical activity
will not pose any health problems.
However, the primary purpose of any
pre-exercise health screening is to identify
individuals who may have health or medical conditions that could put them at risk
during physical testing and exercise. The
American Council on Exercise (ACE), the
American College of Sports Medicine (ACSM),
and other professional organizations for
exercise professionals have determined
that pre-exercise screening is an important
part of the duties of a fitness professional.
According to Heyward (2010), the pretest
health screening of clients that a fitness
professional should minimally complete
before exercise testing and participation
commence must include the following:
• The Physical Activity Readiness
• Identification of signs and symptoms
of disease, if present
• Evaluation of the coronary risk profile
• Classification of heart disease risk factors
The Physical Activity Readiness
The PAR-Q has been designed to identify the small number of adults for whom
physical activity might be inappropriate or
those who should have medical advice concerning the type of activity most suitable
for them (Figure 13-1, pages 286–287).
Identification of Signs and
Symptoms of Disease, if Present
If any signs or symptoms of disease are
present, the client should be referred to
his or her physician for clearance prior to
Exercise Programming
Chapter 13
any exercise testing or participation. Figure
13-2 presents a checklist of some healthscreening signs and symptoms. If a client
checks “yes” beside any of the conditions,
he or she should be advised to obtain medical clearance and/or appropriate exercise
guidelines prior to exercise testing and
participation.
Evaluation of the
Coronary Risk Profile
The coronary artery disease risk factor
threshold is helpful in determining a client
risk profile (Table 13-1, page 288).
Classification of
Heart Disease Risk Factors
The following health-risk categories help
determine a client’s needs for further medical clearance or evaluation before beginning an exercise program.
Despite the recommendations provided
in this section about a person’s potential
health risks regarding exercise, any individual who has the slightest reservations
about his or her ability to undergo exercise
testing or participate in exercise with minimal health risk should consult a physician.
If a client’s health status relative to any of
the PAR-Q questions, coronary risk factors,
or signs and symptoms of disease changes
after starting or modifying an exercise
program, it would be advisable to have the
individual consult a physician.
Low Risk
A low-risk individual exhibits a total of
one or no positive risk factors and no signs
or symptoms of cardiovascular disease.
While a physical examination within the
last year would be appropriate, a low-risk
client is considered safe to participate in
exercise at all of the intensities described
in the ACSM guidelines (ACSM, 2010).
Moderate Risk
A moderate-risk individual exhibits a total
of two or more of the positive risk factors,
but has no signs or symptoms of cardiovascular or pulmonary disease. A prior physical
Figure 13-2
Health screening signs and symptoms questionnaire
examination is appropriate. However, only
individuals who plan to participate in vigorous exercise training or competition need to
obtain prior medical clearance.
High Risk
A high-risk individual exhibits one or
more signs or symptoms of cardiovascular,
pulmonary, or metabolic disease, or has a
known cardiovascular, pulmonary, or metabolic disease. A physical examination and
medical clearance is considered essential
before anyone in this classification participates in exercise programs of any intensity.
Programming Components
P
hysical fitness is defined as a person’s
ability to perform daily, occupational,
and recreational activities without
becoming overly tired and weary. It may also
be described as the ability of the body to
285
Figure 13-1
The Physical Activity Readiness Questionnaire
The Physical Activity Readiness Questionnaire—PAR-Q
(revised 2002)
PAR-Q & YOU (A Questionnaire for People Aged 15 to 69)
Regular physical activity is fun and healthy, and increasingly more people are starting to become more
active every day. Being more active is very safe for most people. However, some people should check with
their doctor before they start becoming much more physically active.
If you are planning to become much more physically active than you are now, start by answering the
seven questions below. If you are between the ages of 15 and 69, the PAR-Q will tell you if you should
check with your doctor before you start. If you are over 69 years of age, and you are not used to being
very active, check with your doctor.
Common sense is your best guide when you answer these questions. Please read the questions carefully
and answer each one honestly: check YES or NO.
YESNO
1.Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
2.Do you feel pain in your chest when you do physical activity?
3.In the past month, have you had chest pain when you were not doing physical activity?
4.Do you lose your balance because of dizziness or do you ever lose consciousness?
5.Do you have a bone or joint problem (for example, back, knee, or hip) that could be made
worse by a change in your physical activity?
6.Is your doctor currently prescribing drugs (for example, water pills) for your blood
pressure or heart condition?
7.Do you know of any other reason why you should not do physical activity?
If you answered Yes to one or more questions:
4Talk with your doctor by phone or in person BEFORE you start becoming much more physically
active or BEFORE you have a fitness appraisal. Tell your doctor about the PAR-Q and which questions
you answered YES.
4You may be able to do any activity you want—as long as you start slowly and build up gradually. Or,
you may need to restrict your activities to those that are safe for you. Talk with your doctor about the
kinds of activities you wish to participate in and follow his or her advice.
4Find out which community programs are safe and helpful for you.
If you answered NO honestly to all PAR-Q questions, you can be reasonably sure that you can:
4Start becoming much more physically active—begin slowly and build up gradually. This is the safest
and easiest way to go.
4Take part in a fitness appraisal—this is an excellent way to determine your basic fitness level so that
you can plan the best way for you to live actively. It is also highly recommended that you have your
blood pressure evaluated. If your reading is over 144/94, talk with your doctor before you start becoming much more physically active.
286
Chapter 13
Delay becoming much more active:
4If you are not feeling well because of a temporary illness such as a cold or a fever—wait until you
feel better; or
4If you are or may be pregnant—talk to your doctor before you start becoming more active.
Please note: If your health changes so that you then answer YES to any of the above questions, tell your
fitness or health professional. Ask whether you should change your physical-activity plan.
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Informed Use of the PAR-Q: The Canadian Society for Exercise Physiology, Health Canada, and
their agents assume no liability for persons who undertake physical activity, and if in doubt after completing this questionnaire, consult your doctor prior to physical activity.
No changes permitted. You are encouraged to copy the PAR-Q but only if you use the entire form.
Note: If the Par-Q is being given to a person before he or she participates in a physical-activity program or a fitness appraisal, this section may be used for legal or administrative purposes.
I have read, understood, and completed this questionnaire. Any questions I had were answered to
my full satisfaction.
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Name
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Signature
Date
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Signature of Parent
Witness
or Guardian (for participants under the age of majority)
ote: This physical activity clearance is valid for a maximum of 12 months from the date it is completed
N
and becomes invalid if your condition changes so that you would answer YES to any of the seven questions.
© Reprinted with permission from the
Canadian Society for Exercise Physiology
Societe canadienne de physiologie de l’exercice
Supported by:
www.csep.ca/forms.asp
Health
Santé
CanadaCanada
287
Table 13-1
Atherosclerotic Cardiovascular Disease Risk Factor Thresholds for Use With ACSM Risk Stratification
Positive Risk Factors
Defining Criteria
Points
Age
Men ≥45 years
Women ≥55 years
+1
Family history
Myocardial infarction, coronary revascularization, or sudden death before 55 years of age in
father or other first-degree male relative, or before 65 years of age in mother or other firstdegree female relative
+1
Cigarette smoking
Current cigarette smoker or those who quit within the previous six months, or exposure to
environmental tobacco smoke (i.e., secondhand smoke)
+1
Sedentary lifestyle
Not participating in at least 30 minutes of moderate-intensity physical activity
(40–60% V02max) on at least three days/week for at least three months
+1
•
Obesity*
Body mass index ≥30 kg/m2 or waist girth >102 cm (40 inches) for men and >88 cm
(35 inches) for women
+1
Hypertension
Systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg, confirmed by
measurements on at least two separate occasions or currently on antihypertensive medications
+1
Dyslipidemia
Low-density lipoprotein (LDL) cholesterol ≥130 mg/dL (3.37 mmol/L) or high-density lipoprotein
(HDL) cholesterol <40 mg/dL (1.04 mmol/L) or currently on lipid-lowering medication; If total
serum cholesterol is all that is available, use serum cholesterol >200 mg/dL (5.18 mmol/L)
+1
Prediabetes
Fasting plasma glucose ≥100 mg/dL (5.50 mmol/L), but <126 mg/dL (6.93 mmol/L) or impaired
glucose tolerance (IGT) where a two-hour oral glucose tolerance test (OGTT) value is ≥140 mg/
dL (7.70 mmol/L), but <200 mg/dL (11.00 mmol/L), confirmed by measurements on at least two
separate occasions
+1
Negative Risk Factor
Defining Criteria
Points
High serum HDL cholesterol
≥60 mg/dL (1.55 mmol/L)
–1
Total Score:
*Professional opinions vary regarding the most appropriate markers and thresholds for obesity; therefore, allied health professionals should use clinical judgment when
evaluating this risk factor.
•
•
Note: V02R = V02reserve
Note: It is common to sum risk factors in making clinical judgments. If HDL is high, subtract one risk factor from the sum of positive risk factors, because high HDL decreases
cardiovascular disease risk.
American College of Sports Medicine (2010). ACSM’s Guidelines for Exercise Testing and Prescription (8th ed.). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins.
adjust to the stresses and demands of physical exertion. More specifically, it is the capacity of the heart, lungs, muscles, and bones to
adapt to the challenges placed upon them.
Technology has advanced civilization to
the point where a person no longer needs to
do much physical effort to survive. Advanced
transportation options, escalators and elevators in malls and businesses, and homes that
are programmed by remote control are hallmarks of modern society. What might have
once taken an hour to do physically can now
288
be accomplished with the push of a button
in a matter of seconds. Unfortunately, these
timesaving amenities and other environmental factors have led many people to adopt
sedentary lifestyles.
The human body is designed for movement and physical activity. To give the body
the physical challenge it needs to be strong
and healthy, a person must make a concerted effort to incorporate physical activity
into his or her daily life. A lack of physical
activity puts each person at a much higher
risk for developing many diseases, such as
heart disease, hypertension, high cholesterol, obesity, diabetes, and musculoskeletal disorders (Warburton, Nicol, & Bredin,
2006). A properly planned exercise program
can play a critical role in combating obesity, heart disease, and musculoskeletal
ailments. LWMCs must consider the following five key components of health-related
physical fitness when developing personalized exercise programs.
to readily perform activities of daily life is
an appropriate goal for all individuals.
Cardiorespiratory Endurance
This sixth component of physical fitness
has received growing attention. Mind/body
vitality refers to an individual’s ability to
minimize or alleviate unnecessary stress
and tension from the body through the
integration of physical exercise and mental
focus. Popular classes such as yoga, tai chi,
and Pilates present constructive means of
harmonizing this union of the mind, body,
and spirit.
Cardiorespiratory endurance, or aerobic conditioning, is the ability of the heart,
lungs, and circulatory system to supply oxygen and nutrients to the working muscles. It
involves the ability to persist in continuous
rhythmic activities such as elliptical training,
walking, jogging, cycling, step training, and
other aerobic activities. Improved cardiorespiratory endurance is associated with decreased
mortality and morbidity for both women and
men (Warburton, Nicol, & Bredin, 2006).
Muscular Strength and Endurance
Muscular strength refers to the capacity
of the muscles to exert maximal or nearmaximal force against a resistance. The
development of stronger muscles leads to the
increased strength and integrity of the body’s
skeletal system. In the cycle of life, muscular
strength may also lessen the chance of injury
(Warburton, Gledhill, & Quinney, 2001).
Muscular endurance is the ability of the
skeletal muscles to exert force, but not necessarily near-maximal force, for an extended
period of time. The ability to increase muscular endurance is often associated with
improved bodily posture, enhanced function
in activities of daily living (ADL), and a
reduced potential for injury.
Flexibility
Flexibility is the range of motion of the
muscles and joints of the body. It involves
the muscles’ normal and trained ability to
extend beyond their natural resting length.
Increasing and maintaining range of motion
Chapter 13
Body Composition
Body composition refers to the proportion
of body fat and lean body tissue (i.e., muscle,
bone, water, and vital organs). Being overfat
is associated with a number of health problems (ACSM, 2010); however, aerobic exercise
and resistance training are effective in positively altering body composition.
Mind/Body Vitality
Cardiorespiratory Training
M
ost of an LWMC’s clients will be participating in some form of cardiorespiratory training, including group
fitness classes. It is important to ask each
client about what type of exercise he or
she performs and to provide tips for reducing injury and maximizing results. Safety is
especially important among overweight and
obese participants, as they tend to be at
a higher risk for injury and often struggle
to keep up with the more fit participants.
Diminished coordination is also a common
problem in this population, which is another reason why safety and careful progression are so important. It is essential that
LWMCs have detailed conversations with
clients about their exercise participation.
The following sections provide information
that should be invaluable during consultation with clients.
According to fitness industry experts, to
develop and maintain cardiorespiratory fitness, individuals should perform endurance
exercise three to five days per week, using an
289
exercise mode that involves the major muscle
groups (in a rhythmic nature) for a prolonged
time period (ACSM, 2010). This includes
physical activities such as step aerobics,
aquatic exercise, cardio-kickboxing, rowing,
and walking. ACSM recommends an intensity of exercise between 64/70% and 93% of
maximum heart rate (or 40/50% and 85% of
oxygen uptake reserve), with a continuous
duration of 20 to 60 minutes per session.
Beginners who are in the lower cardiorespiratory fitness classification should begin with
10 to 20 minutes of aerobic conditioning.
Very deconditioned individuals may be more
suited for multiple sessions of short duration,
such as five to 10 minutes. Inherent in the
exercise design is the concept of individualizing the program for each person’s fitness
level, health, age, personal goals, risk-factor
profile, medications, behavioral characteristics, and individual preferences.
ACSM (2010) recommends that the exercise design for optimizing weight loss should
emphasize the duration and frequency of the
aerobic exercise, keeping intensity moderate
and progressing gradually. ACSM further suggests that the frequency of training should
be five to seven days per week, with the goal
of accumulating 200 to 300 minutes of aerobic activity per week (which is equivalent to
>2,000 kilocalories of exercise per week). This
can be accomplished with longer bouts of
exercise or by performing shorter, 10-minute
bouts of exercise spread out over the week.
These ACSM recommendations for the
development and/or maintenance of cardiorespiratory fitness and for weight loss
serve as the framework for the aerobic fitness designs that follow. A diverse number
of both small and large group-exercise programs have emerged in an effort to meet the
retention needs of regular exercisers, and
to attract new fitness participants. Some of
these programs are choreographed to accompanying music, while others use music as
a background source of inspiration. Some
clients may struggle with choreography, so
LWMCs should be prepared to help them master basic movements. For example, an LWMC
290
may teach a client that music is customarily
arranged in units of two, alternating between
emphasized and deemphasized beats, referred
to as the downbeat and upbeat, respectively.
Some programs, such as step aerobics, follow
a specialized 32-beat phrasing, while other
programs may easily incorporate a blend of
music phrases. Regardless of the music phrasing, the music volume must not put any participants at risk for sustaining hearing loss.
Some of the most popular cardiorespiratory
programs are described in the following sections—step aerobics, mixed-impact aerobics,
mixed-martial arts exercise, indoor cycling,
aquatic exercise, and aerobic interval training.
Step Aerobics
Step aerobics has long been a stronghold
of cardiorespiratory teaching due to its widespread popularity and ease of use with the
varying fitness abilities commonly seen in
exercise classes. Step aerobics, or step training, can be a low-impact exercise program
that provides high-intensity aerobic conditioning for participants (Kravitz, 2006). The
workouts can be as challenging as a rigorous
jogging workout, while producing impact forces that are generally as safe as walking. The
cadence of step aerobics classes ranges from
118 to 126 beats per minute. The most widely
used step platforms have adjustable heights
from 4 to 12 inches (10 to 30 cm), with a
stepping surface 14 (36 cm) inches wide and
42 inches long (107 cm). The progression of
exercise intensity is best adjusted by modifying step height. The typical step platform
risers allow for a 2-inch (5-cm) change in step
height. Encourage participants to begin gradually by using a lower step height, and then
to progressively increase the platform height
as they become more comfortable performing
the instructor-led workouts.
Step-training programs, for the most part,
have been designed to include movements
that are relatively easy to learn and follow.
However, some participants will find the unfamiliarity of stepping on and off of the step to
be a challenging motor skill. One option is to
introduce many of the step combinations gradAmerican Council On Exercise
ually and without musical accompaniment for
these learners. LWMCs should review the following key safety tips regarding step-aerobics
programs with their clients (Kravitz, 2006):
• Step entirely on the top part of the platform with each step; do not allow any
part of the foot to hang over an edge.
• Avoid flexing the knees more than 90
degrees. Most participants find progressing up to a 6-inch (15-cm) step height
to provide a satisfactory workout.
• When using handheld weights [up to 3
pounds (1.4 kg)], modify the arm choreography to slow, controlled, shorter-lever
movements.
• To quickly lower the intensity of the
workout, stop stepping and march in
place on the ground.
• Be careful not to step too far back off
the platform. This causes the body to
lean slightly forward, placing extra
stress on the Achilles tendon and the
muscles of the calf.
• Use a good cross-training or indoorfitness shoe for step workouts. The
tread on most running shoes does not
provide suitable support for the lateral
pathways of step movements.
• Step training involves a stepping
motion using the entire foot. Avoid
pounding foot movements on the platform and bouncing actions onto and
off of the floor.
• Steer clear of step combinations that
travel forward and down off the bench.
• Be aware of the potential for overuse
injury syndrome by participating in a
variety of aerobic activities to allow for
different stresses on the lower body.
• Always look at the step platform when
doing step aerobics, but don’t drop the
head too far forward.
• The correct posture in step training
involves standing tall and bending
at the knees for the ascending and
descending movements. Too much
hip flexion while stepping may place
unwanted stresses on the spine.
Chapter 13
• Change the lead foot when doing step
patterns to avoid overstressing one leg.
A good rule of thumb is to change the
lead foot at least every minute.
• Step-training choreography allows for
some moves to be repeating actions.
Avoid performing more than five consecutive repeating movements on the
same leg.
• Explosive lunges off a step can provide
high-intensity challenges, but are often
performed incorrectly or too swiftly,
with potential trauma to the lower leg
from the ground impact. Take the time
to learn safe lunges and be careful not
to overperform them.
• Participants who complain of knee stress
from a step class should be advised to
seek help from their health practitioner.
Step aerobics may not be a suitable exercise mode for all exercisers.
Mixed-impact Aerobics
Mixed-impact aerobics combines highimpact aerobic movements that are associated with greater stresses on the lower
extremities (such as running and jumping)
with low-impact aerobic movements (such
as side lunges and step touches) that present minimal stress to the lower extremities.
Movement phrases and sequences are choreographed to music that has approximately 130
to 150 beats per minute and incorporate a
variety of arm and leg movements, traveling
patterns, and directional turns. An advantage of mixed-impact aerobic classes is the
ability to easily modify the intensity of the
exercise. With all exercise programs, modification involves analyzing the movements or
exercises and determining safe ways in which
the exercise can be introduced to people of
different fitness levels. The most common
ways to modify any cardiorespiratory mixedimpact exercise design is to alter the speed
of movement, modify the range of motion of
the movement, vary the amount of traveling
completed with a movement, and/or change
the vertical direction of the movement.
291
With mixed-impact classes, there is no
single, preferred method of combining the
impact styles. Some classes alternate impact
styles using the songs to mark the style
changes. For example, some mixed-impact
programs will alternate between high-impact
and low-impact movement with every song
change on a soundtrack (i.e., every three
to five minutes). Other programs combine
the impact styles within all sections of the
choreography, interspersing the low-impact
and high-impact movements throughout the
program. It is essential that group fitness
instructors determine how to best minimize
injury risks while maximizing health benefits. LWMCs should review the following key
safety tips regarding mixed-impact aerobics
programs with their clients (Kravitz, 2006):
• Always wear good aerobic shoes in a
mixed-impact class.
• Encourage all participants to exercise at
their own preferred intensity.
• Regularly monitor exercise intensity
with pulse-rate checks and/or ratings of
perceived exertion (RPE).
• Do not hop on one foot more than four
times in a row.
• Stay away from twisting hop variations
that may lead to spinal stress.
• Drink water before, during, and after
aerobic exercise workouts.
• Gradually slow down the aerobic section to a walking pace to ensure safe
and proper recovery of heart rate, blood
pressure, blood flow, and ventilation.
Mixed Martial Arts Exercise
Kickbox aerobics, aerobic kickboxing,
cardio boxing, and aerobic boxing are just a
few of the many mixed martial arts exercise
formats that are now staples of the fitness
industry. Enthusiasts appear to enjoy the
exhilaration that comes from delivering
kicks, punches, elbows, jabs, knee strikes,
and combinations used in boxing and martial
arts. The athletic drills in these classes are
interspersed with recovery bouts of basic
aerobic movements such as boxer-style rope
skipping (with and without a rope), walking,
292
and light jogging in place. Some mixed martial arts exercise programs involve authentic
boxing gloves, punching bags, and martial
arts equipment, whereas other programs
incorporate a form of “shadowboxing,” which
involves no equipment. The majority of these
classes are driven by moderately paced music
(approximately 120 to 130 beats per minute), although the music in many instances
is more for motivation, since the exercise
program is not always performed to a specific
tempo. Some of the classes are led exclusively
by instructors, while others are taught in
circuit formats, where each participant or
group of participants rotates from station to
station, performing different types of kicks,
jabs, and punches at each station.
A primary concern with mixed martial arts
exercise classes is the ability or qualifications of the instructor to properly teach the
program. LWMCs should remind their clients
that instructors must have proper knowledge
of correct punching techniques and progressive teaching skills to help ensure that
participants avoid any joint-related injuries.
The challenge for these instructors is to create a motivating workout environment while
progressively introducing safe, enjoyable,
and challenging mixed martial arts exercise.
As with all instructor-led classes, the effectiveness of a martial arts instructor largely
depends on his or her ability to modify the
movements to suit the needs and abilities of
the class participants. LWMCs should review
the following key safety tips regarding mixed
martial arts programs with their clients
(Olson & Williford, 1999):
• Perform a satisfactory warm-up to properly prepare the muscles and joints for
the ensuing challenge of the workout.
• With all upper-body strikes and jabs,
make sure the elbow is not taken past
its normal extension range of motion.
• Avoid performing complex upper-body
strike-and-kick combinations.
• Do not execute high repetitions of any
one move.
• Do not do physical-contact exercises
without proper skill progressions.
• Be careful not to kick beyond the normal range of motion.
• Be aware that martial-arts movements
may lead to more delayed onset muscle
soreness (DOMS) in individuals who are
new to these types of workouts.
Indoor Cycling
Indoor cycling classes and sessions have
attracted many devoted enthusiasts. Since
most people know how to ride a bicycle,
indoor cycling presents a cardiorespiratorytraining format that may seem less intimidating. Because of its non-weightbearing
nature, indoor cycling also offers some
orthopedic advantages to those individuals who are unable to perform traditional
weightbearing exercise.
Indoor cycling class formats often
introduce a workout “journey” using
instructor-led visualization and imagery
to create the desired environment for participants (Sherman, 1997). Music selection
in an indoor cycling class is geared toward
enhancing the chosen mood of the “ride.”
No actual beats-per-minute guidelines have
been established for indoor cycling classes.
However, a variety of tempos are often
used to increase or decrease the exercise
intensity (Sherman, 1997). The success
of an indoor cycling class largely depends
on the instructor’s knowledge of exercise
program design and ability to create an
effective workout using his or her leadership skills. In addition, soft-lighting room
designs, with bikes placed close together,
create an atmosphere similar to outdoor
riding with a pack of cyclists. Naturally,
due to the close environment of the exercisers, good air circulation is a must for
indoor cycling classes.
Mainstreaming all fitness levels is easily
accomplished with indoor cycling classes.
Students can control their own workout
intensity with cycling cadence (pedaling
speed), cycle workload (wheel resistance),
and body position (seated or standing position while cycling) (Sherman, 1997).
Chapter 13
Aquatic Fitness
Aquatic fitness classes are popular among
individuals of varying fitness levels. The
resistance afforded by the water provides an
effective environment to perform numerous
exercise movements. Many exercise enthusiasts use the aquatic environment to complete
a greater volume of work with less stress to
the body’s bones and joints. LWMCs should
consider the following key benefits of aquatic
exercise and review them with interested clients (Sanders, 1999):
• Water provides an adequate resistance
overload for resistance training, as well as
a sufficient stimulus for improving cardiovascular function.
• The minimal weightbearing environment
allows for graded exercise intensities
without risk to the lower extremities.
• The aquatic environment gives exercisers
the ability to explore a variety of physical
movements that are different than those
imposed by gravity.
• The external pressure of the water
medium may be suitable for individuals encumbered with blood circulation
problems, as the external pressure of
the water against the body will enhance
venous return.
• The external pressure of the water may
also provide a sufficient challenge for
Attire Suggestions for the
Overweight Aquatic Exerciser
For some overweight individuals, exposing their bodies in the pool area may be
the number-one deterrent or excuse for not participating in an aquatic exercise
program. Fitness professionals need to dress professionally and appropriately,
keeping the larger participants in mind. Inform overweight students of where they
can find large Lycra bike shorts and supportive exercise bras that can be used in
the water. Remind them that they can cover up their swimsuit with other clothing
such as a T-shirt or towel when walking to and from the pool. Encourage them
to focus on how good they will feel about themselves while they are in the water
exercising and for the rest of the day after their workout. Lastly, suggest to them
that they can always arrive a little early to class and stay a little later after class if
they wish to avoid walking in front of the majority of students in the class.
TM
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individuals suffering from weakened
respiratory muscle function.
• The aquatic medium provides a unique
opportunity to modify the range-ofmotion patterns of many exercises and
movements.
• Functional balance and stabilization
movement patterns may be improved and
practiced in the water.
• Clients who fear falling on land may
find the aquatic environment less
intimidating.
• The frequently changing movement
patterns in the water may translate
to improved posture on land, as the
trunk and abdominal muscles are regularly stimulated to maintain posture in
the water.
Generally, the three water depths [in 81
to 84° F (27 to 29° C) water] used in aquaticexercise classes are shallow, which is navel to
nipple; transitional, which is nipple to neck;
and deep, in which the feet are not touching
the bottom of the pool (Sanders, 1999). In
deep-water exercise, some type of buoyancy
gear is required. The choice of water depth
may be determined by what is accessible, the
available aquatic equipment, the participants’
fitness levels, and the desired amount of
weightbearing movement. The shallow-water
environment is ideal for mimicking movements on land without the impact. For some
special populations and physically challenged
individuals, deep-water exercise may be preferred due to its completely non-impact environment (Sanders, 1999).
Exercises in the water can be graded by
the range of motion of performance, the
speed of motion, and the lower-body load
(Sanders, 1999). Lower-body load is higher
at a shallow water level when incorporating more jumping and leaping movements.
In deep-water exercise, the lower-body
movements can be intensified with the
use of aquatic exercise equipment such
as giant aquatic sandals, which add more
resistance to the movement. Finally, for
exercise variety, numerous types of aquatic
equipment, including webbed gloves, fins,
294
and non-buoyant bells, can provide multiple
training-stimulus options to an aquatic exercise program.
Aerobic Interval Training
Interval training has become a popular cardiovascular-training method. One
of the major benefits of interval training is its adaptability to multiple fitness
levels. Aerobic interval training is a form
of conditioning that combines segments
of high-intensity work with segments of
moderate-to-light intensity work. This type
of training systematically emphasizes the
body’s different energy systems (phosphagen, glycolytic, and mitochondrial respiration), thus effectively burning fat and
carbohydrates. The incorporation of interval
training with continuous aerobic programming optimizes the development of cardiorespiratory fitness and can help clients attain
their body-composition goals. Terminology
related to interval training and general
interval-training guidelines for developing
the various energy systems are summarized
in Tables 13-2 and 13-3, respectively.
Although there are many types of
interval-training programs, the following
method has been scientifically tested with
fitness enthusiasts (Kravitz et al., 1997).
An aerobic interval workout should feature
a modality that the client enjoys doing
(e.g., walking, jogging, cycling, rowing,
stair stepping, elliptical training). The aerobic exercise should always begin gradually
with three to five minutes of low-intensity
aerobic activity to prepare the heart, lungs,
and musculoskeletal system for the challenging workout to follow. Following the
warm-up, participants train for four minutes at a higher intensity, followed by four
minutes at a moderate-to-light intensity.
These four-minute intervals alternate for
the duration of the workout. This program
utilizes self-assessed ratings of perceived
exertion to monitor workout intensity.
For example, during the four-minute highintensity interval, the participant should
exercise at an intensity that he or she feels
Chapter 13
Table 13-2
Terms Related to Interval Training
Term
Definition
Work interval
Time of work effort or work bout
Recovery interval
T ime between work intervals. The recovery interval may consist of light activity such as walking
(passive recovery) or mild-to-moderate exercise such as jogging (active recovery).
Work/recovery ratio
T ime ratio of the work and recovery intervals. A work/recovery ratio of 1 to 3 means the recovery time is
three times that of the work interval.
Cycle
One cycle includes a work and recovery interval.
Set
The number of cycles completed per workout
Table 13-3
General Interval-training Guidelines
Energy System
Work Time
Cycles
Sets
Work/Recovery Ratio
Recovery Time
Type of Recovery
0–30 seconds
8–10
4–5
1/3
0–90 seconds
Passive
Glycolytic
30–120
seconds
5–6
1–3
1/2
60–240 seconds
Active
Oxidative
3–5 minutes
3–4
1–2
1/1
2–5 minutes
Active
ATP-PC
Note: Passive recovery means very-low-intensity movement such as walking or even rest; active recovery involves mild-to-moderate intensity.
is “comfortably challenging”; during the
moderate-intensity bout, the client should
feel that the intensity level is “somewhat
challenging.” The alternating variations of
workout intensity will enhance total caloric
burning at the cellular level.
Depending on the individual’s fitness
level, the duration of the workout can gradually increase to 20 to 60 minutes. For cardiovascular maintenance and improvement,
cardiovascular training should be done three
to five times a week, combining the interval
training with other aerobic workouts. To help
a client achieve weight-management goals,
aerobic exercise should be performed five to
seven times per week, regularly alternating
this interval-training workout with long, slow
continuous aerobic training, fast continuous
aerobic training, and Fartlek training (a form
of randomly changing aerobic exercise intensities within the same workout). For variety and
orthopedic-injury prevention, exercises should
alternate all of these various aerobic-training
schemes on different exercise modalities.
Resistance Training
A
lthough resistance training is considered a valuable component of health
and fitness program design, simply
lifting weights does not ensure the desired
outcome. Several factors related to the
client or class must be considered to determine a physiologically sound approach to
achieve the program’s goals. Some of the
basic elements of the resistance-training
plan include:
• Assessing the initial fitness level of
the client
• Setting short- and long-term goals
• Identifying specific muscle groups to
work
• Choosing the type of exercise equipment
• Selecting the type and order of the
exercises
• Manipulating the frequency, intensity,
and duration of the workouts, as well
as the number of repetitions, types of
295
contraction, rest periods, and sets during the workout
• Planning ahead for the progressive
overload
• Motivating the client to comply to the
program
Considering all of these factors, the likelihood of one training program meeting the
needs of all participants is highly impractical. Resistance-training programs designed
specifically to enhance musculoskeletal
fitness have been effective in improving
several indicators of health status, including bone health, glucose metabolism, overweight and obesity, the incidence of falling
and associated injuries, activities of daily
living, and/or psychological well-being
(Warburton, Gledhill, & Quinney, 2001). In
weight-management programs, resistance
exercise is vital for helping to preserve muscle mass (which is metabolically active tissue) during the weight-loss process (Jackicic
et al., 2001). Following are the answers to
some key questions that LWMCs may hear
about resistance training (Kravitz, 2006):
• What is a concentric muscle action? A
concentric muscle action (or contraction) involves a muscle going through
a shortening motion as it overcomes
resistance.
• What is an eccentric muscle action?
During eccentric muscle actions (or
contractions), the muscle lengthens as
it resists the load. During a biceps curl,
for example, the upward phase of the
movement is the concentric action and
the lowering phase of the movement is
the eccentric action.
• What is an isometric action? During
isometric muscle actions (or contractions), a muscle is stimulated to
develop tension, but no joint movement occurs. Isometric contractions
represent the amount of strength an
individual can exhibit at a fixed point
in the range of motion. With isometric
actions, there is no limb movement or
change in the joint angle. Holding a
296
weight in one position is an example of
isometric strength.
• What is speed strength? Speed strength
is a relatively new term that is interchangeable with the term power. Speed
strength refers to the maximum force
exhibited over a distance at a certain
speed of movement. Examples of speed
strength in sports include swinging a
bat, throwing a javelin, and striking a
punching bag.
• What is absolute strength? Absolute
strength is the maximal amount of
weight that an individual can lift one
time. It is sometimes referred to as the
one-repetition maximum (1 RM).
• What is relative strength? Relative
strength compares the strength of
different individuals. It is the ratio
of the amount of weight lifted to the
total body weight of the person. For
example, if a 120-pound (54.5-kg) person can do a 1 RM biceps curl with a
50-pound (23-kg) weight, the relative
strength of this muscle group can be
determined as follows: 50 pounds/120
pounds (23 kg/54.5 kg) = 0.42. Relative
strength is reported as a percentage;
therefore, in this example, multiplying
0.42 by 100 means the relative strength
of the biceps muscle is 42%.
• What is functional strength? Functional
strength is a popular term used in both
fitness and sports. In fitness, functional
strength is often discussed in terms
of doing exercises that will enhance
a person’s ability to execute everyday
activities. Some experts describe this
strategy as “meaningful exercise” to
enhance daily physical tasks. With
functional strength, exercises are chosen that are task-specific to help a person perform better in daily life.
In sports, the term functional
strength is used to describe applied
strength that results in improved
sports performance. For recreational
and competitive athletes, trainers and
coaches try to duplicate the range of
motion (or a portion of the range) with
an exercise. For example, a push-up is
excellent for developing the strength of
the shoulder joint, yet it is not the best
functional exercise choice for training
a golfer. When working with a golfer,
a better option would be to design an
exercise that goes through more of a
diagonal pathway, which mirrors the
motion of swinging a golf club.
• What is core strength? Core strength
and core stability are relatively new
concepts in strength training. Coretraining exercises are designed to
strengthen the deep spinal muscles—
the deep abdominal and lower-back
muscles surrounding the spine, often
referred to as the intrinsic muscles. The
purpose of core training is to spare the
spine from damage. Core strength training creates a stable and mobile lower
back, which may in turn improve exercise performance and enjoyment.
Resistance training is an effective method
for maintaining and increasing lean body
mass and improving muscular strength and
endurance. Resistance-training programs
should be designed to meet the needs and
goals of the individual. All training programs need to be monitored and evaluated
closely. LWMCs should be acutely aware of
the many signs and symptoms of overtraining: muscle soreness, injury, fatigue, drops
in exercise performance, attitude changes,
unplanned drops in body weight, sickness,
tiredness, and restlessness. If any one of
these signs, or a combination of these signs,
is observed, rest or a change in the training
program is necessary. LWMCs can use the
following checklist of questions as an effective needs analysis when designing a safe
and appropriate resistance-training program
for clients:
• What results does the client want to
achieve?
• What component of muscular fitness
(strength, endurance, speed, power,
or some combination of these components) does the client want to improve?
Chapter 13
• Are there any movement patterns that
need to be developed?
• What muscle groups need to be developed?
• Are there any specific muscle imbalance
concerns?
• How is the client’s muscular fitness
going to be assessed (e.g., 1 RM, 5 RM,
10 RM, trial-and-error method)?
• What is the client’s health history? Are
there any past injuries or chronic limitations that need to be addressed?
• Have the short- and long-term goals
been collaboratively written with the
client?
• Where will the workouts take place
(e.g., class, gym, home facility)?
• What equipment is available or needed?
• What days/times are available and recommended for the client’s workout?
• Approximately how long will each
training session last?
• What methods of resistance training
will be included in the program?
• What types of exercises will be predominantly chosen for the client?
• What order of exercises will be used in
designing the workouts?
• What workout intensity will be used in
the sessions?
• How many sets and repetitions will be
utilized?
• How much rest will there be between
sets and exercises?
• What type of a warm-up and cool-down
will be utilized?
• How will the client’s progress be monitored and evaluated?
ACSM (2010) recommends a minimum of
one set of eight to 10 exercises (multijoint
and single joint) that involve the major
muscle groups (at a sufficient intensity to
enhance the development and maintenance
of muscular strength and endurance), performed two to three times a week for healthy
participants of all ages. A more technical and
advanced form of training known as periodization training is discussed in the following section.
297
Periodization
Periodization is a systematic approach to
training that involves progressively cycling
various aspects of a training program during a specific period of time. The roots
of periodization come from Hans Selye’s
model, known as the general adaptation
syndrome (Selye, 1976), which has been
used by the athletic community since the
late 1950s. Selye identified a source of biological stress referred to as eustress, which
denotes beneficial muscular strength and
growth, and a distress state, which is stress
that can lead to tissue damage, disease,
and death. Periodization is most widely
used in resistance-training program design
to avoid overtraining and to methodically alternate high loads of training with
decreased loading phases to improve components of muscular fitness (e.g., strength,
strength- speed, muscular endurance).
This system of training is traditionally divided up into three types of cycles:
microcycles, mesocycles, and macrocycles. A microcycle generally lasts up to
seven days. A mesocycle may last anywhere
from two weeks to a few months and can
be classified as a preparation, competition,
peaking, or transition phase. The macrocycle refers to the overall training period,
usually a year.
Periodization Models
Periodization, as it has been defined,
refers to specific methods of manipulating
the volume and intensity of the training.
Traditional models of periodization describe
a progression from high-volume and lowintensity work toward decreasing volume
and increasing intensity during the different
cycles (Table 13-4). Other periodization programs have been developed that also have
potential advantages over nonperiodized
approaches. A method that utilizes a reduction in volume and an increase in intensity
in distinct steps during the training cycle
is referred to as stepwise periodization. In
the overreaching periodization model, there
is a periodic short-term (one- to two-week)
298
increase in volume or intensity, followed
by a return to normal training. The newest concept in periodization is undulating
periodization (Figure 13-4). With undulating
periodization, training volume and intensity are increased and decreased during the
course of a microcycle (seven-day period).
While the body of research pertaining
to periodization focuses on the effect of
varying volume and exercise intensity, it
should be clear that these are not the only
variables that determine training adaptations. Other influential components that
are addressed in program design include
the following:
• Choice and number of exercises
• Order of exercises
• Resistance or load
• Number of sets per exercise
• Number of exercises per muscle group
• Repetition range(s)
• Type of contraction(s) emphasized and
varied (i.e., concentric, eccentric, and
isometric)
• Speed of movement
• Rest periods between sets
• Rest periods between training sessions
• Nutritional status of the client
Further research on periodized training programs is needed. However, for more
advanced resistance-training designs, the
evidence appears to strongly recommend
utilizing a periodized approach as compared
to constant repetition/set–type programs
(Kraemer & Fragala, 2006).
Circuit Training
Circuit training is a popular resistanceexercise format that can be utilized with all
populations and fitness levels, especially
those in weight-loss programs. Circuit training was developed by R.E. Morgan and G.T.
Anderson in 1953 at the University of Leeds
in England (Kravitz, 1996). The term “circuit” refers to a number of carefully selected
exercises arranged successively. In the original format, nine to 12 stations comprised the
circuit, but this number may vary according
to the design goals of the program. Each
Chapter 13
Table 13-4
Traditional Periodization Design
Hypertrophy
Strength &
Hypertrophy
Strength
Transition
Sets
1–5
1–5
1–5
1–2
Reps
9–12
6–8
1–5
13–20
Weeks
2–3
2–3
2–3
1–2
Note: For each period, the “rep zone” represents the intensity at which all exercises are performed to momentary muscular fatigue. Daily workout
decisions are made regarding the type and number of exercises, order of exercises, loads to attain muscular fatigue in the rep zone, number of
sets per exercise, number of exercises per muscle group, type of contraction(s) emphasized (i.e., concentric, eccentric, and isometric), speed of
movement, rest periods between sets, and rest periods between training sessions.
3–5 RM
3–5 RM
8–10 RM
8–10 RM
12–15 RM
MonWed Fri
Week
12–15 RM
MonWed Fri
Week
3–5 RM
3–5 RM
8–10 RM
12–15 RM
MonWed Fri
Week
participant moves from one station to the
next with little (15 to 30 seconds) or no rest,
performing a 15- to 45-second set of eight
to 20 repetitions at each station (using a
resistance of about 40 to 60% of 1 RM). The
program may be performed using one or
more of the following: exercise machines,
hand-held weights, elastic resistance, or
calisthenics. The circuit is often repeated
one to four times, depending on the fitness
level and goals of the client.
Adding a 30-second to three-minute (or
longer) cardio station between each resistance
8–10 RM
12–15 RM
MonWed Fri
Week
Figure 13-4
Undulating periodization
design
Note: Typically, this method
is utilized as a total-body
workout scheme with
seven to 10 exercises for
the major muscle groups
performed during each
workout. Daily workout
decisions are made regarding the type and number of
exercises, order of exercises, loads to attain muscular
fatigue in the “rep zone,”
number of sets per exercise, number of exercises
per muscle group, type of
contraction(s) emphasized
(i.e., concentric, eccentric,
and isometric), speed of
movement, rest periods
between sets, and rest
periods between training
sessions.
station (referred to as aerobic circuit training)
promotes greater energy expenditure, which is
desirable in weight-loss programs. One variation of this aerobic circuit-training model
involves performing two, three, or four or
more exercise stations consecutively, and then
performing the cardio station. Table 13-5 presents a sample aerobic circuit-training workout
that features a cardio station interspersed
between every two resistance-exercise stations. Note the use of different aerobic modes
for variety in this aerobic circuit design.
299
Table 13-5
Sample Aerobic Circuit-training Workout
• Chest fly
• Leg press
• 3-minute session on cycle ergometer
• Row pull
• Traveling lunge
• 3-minute session on treadmill
• Lat pull-down
• Shoulder press
• 3-minute session on elliptical trainer
• Triceps extension
• Biceps curl
• 3-minute session on cycle ergometer
• Heel raise
• Squat
• 3-minute session on rowing ergometer
Lifestyle Fitness Activities
S
pontaneous physical activity is defined
as the physical activity in a person’s
daily life that is not purposely structured. Researchers have begun to study
the role that daily spontaneous standing,
walking, and fidgeting movements play
in combating weight gain and obesity;
spontaneous physical activity is currently
gaining great attention and scientific support as a possible (and novel) approach to
combating the rise of obesity in children
and adults (Levine et al., 2005). From this
research, scientists have defined a new
component of energy expenditure called
non-exercise activity thermogenesis (NEAT)
(physiological processes that produce
heat). Levine and colleagues have revealed
some unexpectedly useful data in this area.
NEAT represents the energy expenditure
of daily activities such as standing, walking, moving, and shifting while sitting—all
activities that are not considered planned
physical activity in a person’s daily life. To
measure NEAT, investigators utilize highly
sensitive monitoring devices known as
inclinometers and triaxial accelerometers
that are worn on the hips and legs. These
devices capture data on body-position
300
movements in all planes of movement 120
times per minute. Combining this information with other laboratory measurements of
energy expenditure leads to a calculation
of NEAT. The following are some particularly interesting research highlights on NEAT
that may better explain the efficacy of this
approach in increasing lifestyle fitness and
verify the practicality of its use by fitness
professionals in helping clients battle overweight and obesity.
Levine and colleagues (2005) recruited
20 healthy volunteers, all of whom did
no structured physical activity. Of the 20
volunteers, five men and five women had
body mass index (BMI) measurements of
23 ± 2 kg/m2 (classifying them as lean) and
five men and five women had BMI measurements of 33 ± 2 kg/m2 (classifying them as
Grade I obese; see Table 17-3, page 378).
The authors noted that such a population
was selected because they were less likely to
have medical impediments and orthopedic
troubles as compared to a morbidly obese
group. Each subject wore an inclinometer
and triaxial accelerometer and data were
collected every half-second for 10 days.
Researchers were looking for lifestyle
physical activity clues that might explain
why 10 non-exercising lean men and women varied from 10 non-exercising mildly
obese men and women. They found that
the obese subjects were seated for 164 minutes longer each day than the lean participants. Additionally, the lean participants
were standing and moving for 153 minutes
more per day than the obese subjects.
Sleep times between the two groups did
not vary at all. Thus, the lean subjects had
significantly more total-body ambulatory
movement, which consisted of standing
and walking. Amazingly, this extra movement by the lean subjects averaged 352 ±
65 calories per day, which is equivalent to
36.5 pounds (16.6 kg) of fat in one year.
Despite the time and effort spent
designing structured exercise programs
for clients wishing to achieve fitness and
weight-management goals, not all individuAmerican Council On Exercise
als will maintain their exercise program.
According to ACSM (2010), approximately
50% of people drop out of exercise within
the first six months. Therefore, another
important key to helping people attain
their fitness and weight-loss goals is to find
new behaviors that encourage more mobility in their daily lives. The U.S. Department
of Health & Human Services has established
a ”Get Active” website (www.SmallStep.
gov) to help individuals increase their levels of spontaneous physical activity. Table
13-6 presents a few of the many suggestions provided at this website to help people get moving and become more physically
active during the day. Teaching clients how
to make small movement changes in their
daily lives may significantly contribute to
some desirable changes in their overall fitness and weight-management goals.
Chapter 13
Table 13-6
L ifestyle Suggestions to Help Clients
Be More Active During the Day
• Walk to work.
• Walk during your lunch hour.
• Walk instead of drive whenever you can.
• Take a family walk after dinner.
• Skate to work instead of driving.
• Mow the lawn with a push mower.
• Walk to your place of worship instead
of driving.
• Walk your dog.
• Replace the Sunday drive with a
Sunday walk.
• Get off the bus a stop early and walk.
• Work and walk around the house.
• Take your dog to the park.
The SPORT Principle
T
he body adapts to the demands placed
upon it. It is important to follow some
basic principles of exercise training
and progression when designing an exercise program to improve a client’s level of
fitness. The following training tactics are
known as the SPORT principle: specificity,
progression, overload, reversibility, and
training effect (Kravitz, 2006).
Specificity
Specificity takes the guesswork out of
training. This training principle states that
for an individual to become proficient at
any given movement, that movement itself
must be trained and practiced. The body
will adapt to the specific type of training
placed upon it. Marathons, for example,
require long-distance or high-volume
endurance training. LWMCs should keep
specificity in mind when working with
clients, as adherence to this principle will
allow clients to develop fitness and movement strategies that will help them when
the time comes to actually perform the goal
movements.
• Wash the car by hand.
• Run or walk fast when doing errands.
• Pace the sidelines at your kids’ athletic games.
• Take the wheels off your luggage.
• Walk to a coworker’s desk instead of emailing
or calling.
• Make time in your day for physical activity.
• If you find it difficult to be active after work, try
to fit exercise in before work.
• Take a walk break instead of a coffee break.
• Perform gardening and/or easy-to-do homerepair activities.
• Bring your groceries (from your car)
into your house one bag at a time.
• Play with your kids at least 30 minutes
a day.
• Dance to music.
• Walk briskly in the mall.
• Take the long way to the water cooler
or break room.
• Take the stairs instead of the escalator.
• Go for a hike.
301
Progression
The human body responds much more
efficiently to gradual and progressive challenges. With each new physical challenge,
the physiological systems of the body
challenged by the exercise will adapt with
improved functioning ability. Gradual progression is the key to a successful training
program. The early research of Hans Selye
(1976) demonstrated that for progression
to continue and physical exhaustion to
be avoided, the exercise stimulus must be
regularly and gradually increased.
Overload
Overload is introduced by increasing
the intensity, duration, or frequency of an
established level of exercise. For example,
a cardiovascular-training program may be
overloaded by adding another training bout
during the week, lengthening the training sessions, or training at a higher level
of cardiovascular intensity. In resistance
training, overload is easily introduced by
using heavier weights or by doing more
repetitions. In flexibility, overload is created by doing additional stretches or trying
to stretch further than the previous limits.
If the exercise program becomes too easy or
somewhat routine, it may be appropriate to
add exercise overload. The body will adapt
and develop a new training threshold,
beyond which new benefits occur.
Reversibility
Consistent exercise is essential for maintaining the benefits of exercise, because
these benefits cannot be stored; instead,
they are reversible. If a person stops exercising, the body will adapt to the decreased
exercise demands and start to decline from
the previous fitness level.
Training Effect
Fitness levels are improved with regular, progressively overloaded training
programs. This is known as the training
effect. How much a person can improve is
closely associated with his or her initial
level of fitness, lifestyle habits, motivation,
302
time investment in exercise, and certain
genetic endowments. Regularly evaluating
a client’s progress can provide the information needed to establish an appropriate
maintenance stage that coincides with the
client’s desired health and fitness goals.
At this stage, the goal is to maintain this
training effect by continuing with the exercise program, not adding more overload.
Functional Exercise
Progression
Y
oke and Kennedy present a new
method of exercise selection and
progression in their book, Functional
Exercise Progressions (2004). This novel
design progresses from simple to complex
exercises that strengthen the core muscles
(i.e., internal obliques, tranverse abdominis,
multifidus, quadratus lumborum). Yoke and
Kennedy’s six-step exercise design system
consists of the following:
• Step #1: Isolate and educate. The student is learning how to focus on the
muscle and movement. Exercises in
this level are often performed in the
supine or prone position.
• Step #2: Isolate, educate, and add
resistance. Add resistance to the exercises used in Step #1.
• Step #3: Add a functional-training
position. To better challenge the stabilizing muscles, clients can perform
exercise in a seated or standing position (for the targeted muscles).
• Step #4: Combine the functional challenge with resistance. Add some type
of overload (e.g., weights, tubing,
bands) to challenge the body’s stabilizers in the functional position.
• Step #5: Involve multiple muscle
groups with increasing resistance and
core challenge. Clients can perform
more complex exercises (e.g., squats,
lunge variations) that combine muscular fitness, balance, coordination, and
stability.
• Step #6: Add balance, increased functional challenge, speed, and/or rotational movements. Use stability balls,
wobble boards, and/or spinal rotation
with the exercise movements. Yoke and
Kennedy (2004) note that some individuals may never reach this level due
to their fitness level or health history.
Exercise Precautions
and Modifications
A
lthough there are many health benefits of exercise, there are also several
precautions of which an LWMC must be
aware to maximize exercise safety. This section presents general precautions, concerns
for exercising outdoors or in hot environments, precautions for special populations
and the elderly, and alert signs for a stroke
or a heart attack.
General Precautions
• Advise clients to always warm up before
exercise. Usually a five- to sevenminute general warm-up on a treadmill,
stationary bike, elliptical cross-trainer,
or other aerobic mode is sufficient to
prepare the cardiorespiratory and metabolic systems of the body for the workout to follow. A specific muscle-joint
warm-up of light overload exercises is
also recommended before moderate-toheavy physical activity.
• Make sure clients learn how to perform
the correct movement techniques for
all exercises before progressively overloading the musculoskeletal system.
Teach clients to exhale on the exertion
when lifting heavy weights to avoid
the Valsalva maneuver, which occurs
when the glottis restricts air through
the trachea, dramatically increasing
thoracic pressure.
• Exercising too soon after a meal may
hamper oxygen and nutrient delivery
to the working muscles, leading to
gastrointestinal distress. Advise clients
to wait at least 60 to 90 minutes after
Chapter 13
a complete meal before engaging in
moderate-intensity exercise. As a
general rule, the higher the exercise
intensity, and/or the greater the
amount food consumed, the longer the
time should be between eating and
exercising.
• Teach clients how to correctly stack
weights on barbells and to always use
safety pins when using free weights.
• Advise clients to wear well-fitting and
appropriate workout shoes and comfortable-fitting fitness clothing that allows
the body to readily dissipate heat.
Encourage them to wear less jewelry
during workouts, as it may be damaged
from the physical movements of the
exercise, or possibly injure someone.
• Many people starting an exercise program do “too much, too soon, too
hard,” leading to pointless muscle soreness and possible injury. Encourage
clients to start slowly and to incrementally increase the intensity and duration of their workouts.
• Promote the concept of “comfortably
challenging” workouts, as opposed to
training sessions that achieve total
exhaustion. “No pain, no gain” has no
scientific substantiation.
• An adequate cool-down (or recovery)
is necessary to bring the body’s physiological processes to pre-exercise levels.
Include stretching exercises to facilitate
relaxation of the muscles that have
been vigorously contracting.
• Urge clients to hydrate before, during, and after the workout. Also, it is
advisable to avoid caffeine or alcohol
before and during exercise, as they may
further dehydrate the body. Alcohol
may also substantially affect a person’s
balance and judgment.
• It is a good idea to vary the intensity
of workouts. Performing two highintensity workouts in a row may cause
undue exhaustion, leading to possible
overtraining and overuse complications.
303
•W
hen training during vigorous exercise,
encourage clients to slow down if they
feel out of breath. For most people,
being able to talk while exercising is a
good indicator of appropriate exercise
intensity, while gasping for breath is a
sign of exercising too strenuously.
• T each clients how to listen to their
bodies. The human body has a remarkable sensory message system that
informs one if there is pain, discomfort, and injury. Pain is an important
message that tells an exerciser to slow
down and/or stop.
•D
on’t urge clients to push through
injuries, as doing so can lead to greater
health problems. If pain persists for
more than a few days, clients may need
to seek the advice of a qualified healthcare professional.
Concerns for Exercising
Outdoors or in Hot Environments
Environmental pollutants can be a concern when exercising outdoors or in big cities. Have clients learn where these unsafe
areas are in their city and have them keep
away from them whenever possible.
Encourage clients to wear sunscreen
when exercising outdoors, especially in
sunny environments.
Exercising in hot weather increases the
risk of injury and other complications. The
following guidelines will help clients avoid
heat stress (see Chapter 3 for more on these
environmental considerations):
• Drink water before, during, and after
exercise.
• Wear loose-fitting clothes that allow for
evaporation of sweat from the body onto
the clothes.
• Avoid training during the hottest part of
the day, usually between 10 a.m. and 4
p.m. (during the summer).
• Allow one to two weeks for
acclimatization to a hot environment.
• Decrease workout intensity in a hot
environment if necessary.
• Remember that some people are more
304
heat-sensitive than others; this includes
those who are overweight, obese, unfit,
older, or have any combination of these
conditions.
Precautions for Special
Populations and Older Adults
It is essential to be able to identify
those clients who may not have normal
joint integrity or have diseases or disorders that could alter exercise performance.
Seek council from a healthcare professional
to determine appropriate precautions and
modifications for any exercise program
(see Chapter 18). For example, one in three
Americans have high blood pressure and
many are not aware of this health risk
(which is why it is called the “silent killer”)
(Centers for Disease Control and Prevention,
2010). Hypertensive persons should not
engage in high-intensity resistance exercise,
as the increase in thoracic pressure may
dangerously elevate blood pressure.
Exercise is one of the best things that
older adults can do to improve quality of
life. However, in addition to the general
precautions, older adults must adhere to the
following safety measures:
• For some seniors, the body may not be
as flexible or supple as it used to be.
Therefore, range-of-motion exercises
that help clients perform ADL should be
included in the fitness program.
• A basic rule for initiating exercise
programs with older adults is to start
slowly and then progress very gradually.
Help them learn to adjust progressively
to the new requirements of daily
exercise and physical activity.
• Seniors often take medications that
affect heart rate, blood pressure, and
standing balance. Discussing any
concerns with an appropriate health
practitioner will enable a fitness
professional to properly design safe
and effective workouts for these older
clients.
• For seniors, a good warm-up includes
adequately preparing the musculoAmerican Council On Exercise
skeletal and cardiorespiratory systems,
as well preparing the mind to facilitate
mental readiness of the upcoming
exercises.
•A
mong older adults, falls are the
leading cause of injuries, hospital
admissions for trauma, and deaths due
to injury. Fractures are among the most
serious health consequence of falls.
Many of these falls and their resulting
injuries are preventable. Strategies for
preventing falls in older adults include
incorporating exercises to improve
strength, balance, and flexibility;
exercising close to grab bars; improving
lighting; and removing items that may
cause tripping.
Signs of Stroke or Heart Attack
The symptoms of stroke are distinct and
happen quickly. If a client is exhibiting any
of the following symptoms and appears to
be having a stroke, the LWMC should call
911 immediately:
• S udden numbness or weakness of the
face, arm, or leg (especially on one side
of the body)
• S udden confusion and trouble speaking
or understanding speech
• S udden trouble seeing in one or both
eyes
• S udden trouble walking, dizziness, or
loss of balance or coordination
• S udden severe headache with no known
cause
The American Heart Association (www.
americanheart.org) and other medical
organizations advise that heart attack
victims will experience one or more of the
following warning signals:
•U
ncomfortable pressure, fullness,
squeezing, or pain in the center of the
Chapter 13
chest lasting more than a few minutes
• Pain spreading to the shoulders, neck, or
arms. The pain may be mild to intense
and may be located in the chest, upper
abdomen, neck, jaw, or inside the arms
or shoulders
• Chest discomfort with lightheadedness,
fainting, sweating, nausea, or shortness
of breath
• Anxiety, nervousness, and/or cold,
sweaty skin
• Irregular or abnormally accelerating
heart rate
• A pale face
Not all of these signs occur with every
heart attack. A doctor who has studied
the results of several tests must make the
actual diagnosis of a heart attack. However,
if a client appears to be experiencing a
heart attack, the LWMC should call 911
immediately.
Summary
E
ducating and motivating clients to
make a commitment to a physically
active lifestyle of exercise and spontaneous movement may very well contribute
to some desirable and profound changes to
their overall health and weight-management
goals. LWMCs need to take the leadership
role in helping clients help themselves to
positive health through meaningful physical-activity programming. By successfully
doing this, LWMCs will indeed be meeting
“head on” some of the most difficult health
challenges facing modern society, including
diabetes and obesity.
305
References
Sanders, M.E. (1999). Cross over to the water.
IDEA Health and Fitness Source, 17, 3, 53–58.
ACSM’s Guidelines for Exercise Testing and
Prescription (8th ed.). Philadelphia: Wolters Kluwer/
Lippincott Williams & Wilkins.
Selye, H. (1976). Forty years of stress research:
Principal remaining problems and misconceptions.
Canadian Medical Association Journal, 115, 53–56.
Centers for Disease Control and Prevention
(2010). High Blood Pressure Facts.
www.cdc.gov/bloodpressure/facts/htm.
Heyward, V.H. (2010). Advanced Fitness
Assessment and Exercise Prescription (6th ed.).
Champaign, Ill.: Human Kinetics.
Jakicic, J.M. et al. (2001). Appropriate intervention
strategies for weight loss and prevention of weight
regain for adults. Medicine & Science in Sports &
Exercise, 33, 2145–2156.
Kraemer, W.J. & Fragala, M.S. (2006). Personalize
it: Program design in resistance training. ACSM’s
Health & Fitness Journal, 10, 4, 7–17.
Warburton, D.E., Gledhill, N., & Quinney, A. (2001).
The effects of changes in musculoskeletal fitness
on health. Canadian Journal of Applied Physiology,
26, 161–216.
Warburton, D.E., Nicol, C.W., & Bredin, S.S. (2006).
Health benefits of physical activity: The evidence.
Canadian Medical Association Journal, 174,
801–809.
Yoke, M. & Kennedy, C. (2004). Functional Exercise
Progressions. Monterey, Calif.: Healthy Learning.
Kravitz, L. (2006). Anybody’s Guide to Total Fitness
(8th ed.). Dubuque, Iowa: Kendall/Hunt Publishers.
Suggested Reading
Kravitz, L. (1996). The fitness professional’s
complete guide to circuits and intervals. IDEA
Today, 14, 1, 32–43.
ACSM’s Resource Manual for Guidelines for
Exercise Testing and Prescription (6th ed.).
Philadelphia: Lippincott Williams & Wilkins.
Kravitz, L. et al. (1997). Does step exercise with
handweights enhance training effects? Journal of
Strength and Conditioning Research, 11, 194–199.
Levine, J.A. et al. (2005). Interindividual variation in
posture allocation: Possible role in human obesity.
Science, 307, 584–586.
Olson, M.S. & Williford, H.H. (1999). Martial arts
exercise: A T.K.O. in studio fitness. ACSM’s Health
& Fitness Journal, 3, 6, 6–13.
306
Sherman, R.M. (1997). The indoor cycling
revolution. IDEA Today, 15, 3, 30–39.
Fleck, S.J. & Kraemer, W.J. (2004). Designing
Resistance Training Programs (3rd ed.). Champaign
Ill.: Human Kinetics.
Kennedy-Armbruster, C.A. & Yoke, M.M. (2009).
Methods of Group Exercise Instruction (2nd ed.).
U.S. Department of Agriculture. Dietary Guidelines
for Americans. www.health.gov/dietaryguidelines
Debra Wein
Debra Wein, M.S., R.D., L.D.N., C.S.S.D., NSCA-CPT, is on the faculty at
the University of Massachusetts Boston and Simmons College, and is
the president of Sensible Nutrition, Inc. She has worked with the United
States of America Track and Field Association, National Hockey League,
Boston Ballet, and numerous marathon training teams.
Chapter 14
Nutritional Programming
Implementing a Nutrition Program
C
lients will often describe schedules that barely allow them
enough time to sleep, let alone eat healthy meals and exercise regularly. Grocery shopping and preparing meals are
often out of the question. Even though they may be well aware
that fueling their bodies with healthy foods is important, “life”
often gets in the way.
It is important to help clients understand that they won’t
find the time to exercise and eat right—they must make the
time. Contrary to popular belief (or popular excuses), eating
a healthy diet is not impossible. Like anything else, it takes
knowledge, practice, and planning to set goals and overcome
barriers. (For more information on assessing a client’s readiness
for change, see Chapter 15.)
Eating behaviors, which are among the most complex of human
behaviors, are learned habits that are deeply entrenched and
strongly influenced by religious, ethnic, and family customs.
Emotional influences also play an important role in why, when,
and what people eat. But it is possible for people to “relearn” how
to eat more healthfully. The processes of eating, cooking, and
choosing foods are shaped by one’s past, but these behaviors can
be modified. Behavior modification, however, takes time. When
working with clients, the focus should remain on gradually modifying eating and exercise behaviors, both of which are necessary for
IN THIS CHAPTER:
Implementing a
Nutrition Program
The Nutrition Interview
Understanding a Client’s
Current Dietary Habits
Food Diary/Food Record
24-hour Recall
Food-frequency Questionnaire
Food Models and Portion Estimates
Using the 2005 USDA
Dietary Guidelines
Addressing A Client’s Nutritional
Needs While Staying Within the
LWMC’s Scope of Practice
Nutritional Program Planning
for the Weight-loss Client
Estimating Caloric Needs
Using Caloric Information
to Affect Weight
Summary
Chapter 14 Nutritional Programming
sustainable weight loss. Lifestyle & Weight
Management Coaches (LWMCs) should remind
clients that small, permanent changes in
both behavior and weight loss are better
than large, temporary ones.
Behavior modification involves the following:
• Modifying old ways of eating and developing healthier eating habits
• T aking small steps in a consistent
direction
• Focusing on environmental or situational control of eating in a program that is
designed to reduce the exposure, susceptibility, and response to environmental situations that result in high calorie
intake and/or low energy expenditure
• Self-monitoring and self-management
The Nutrition Interview
Understanding a Client’s
Current Dietary Habits
An effective way to learn about a client’s
current dietary habits is to administer a
lifestyle and health-history questionnaire
(Figure 14-1), which may be used to identify
clients whose needs fall outside the scope
of practice of an LWMC. Alternatively, this
questionnaire can be administered by the
LWMC in an interview format, which might
stimulate greater conversation and insight.
Several methods can be used to learn more
about a client’s eating and lifestyle patterns,
including food diaries, food records, 24-hour
recall, and food-frequency questionnaires.
With practice, an LWMC may find that certain
clients may be very likely to complete food
records, while others may only be willing or
able to give a 24-hour diet recall. Regardless
of which method is used, the information
gleaned from these tools will be invaluable in
helping clients meet their goals.
Food Diary/Food Record
Keeping a food diary involves having clients describe a “typical” eating day, including all foods and beverages (Figure 14-2).
Clients should be urged to be specific and
310
estimate amounts as best they can. Be sure
to discuss weekends versus weekdays. Space
is provided in the food diary for the client to
note how hungry he or she is when the food
is consumed. Additional space could be added
to include information on mood, location,
and time of day for more detailed intake
information.
One thing to consider is that people
generally underestimate or under-report
their caloric intake and tend to eat more
salads, vegetables, and lower-calorie foods
when using a food diary than their weight
might suggest. Experience with probing the
client, asking nonjudgmental questions,
and offering a supportive environment is
likely to reveal a more truthful picture of a
client’s eating pattern.
Proper instruction on how to keep food
records will often yield better results than just
handing a client a sheet of paper and telling
him or her to “write down what you eat.”
LWMCs should share the following guidelines
with clients to help them more accurately
report their food intakes (Figure 14-3):
• Keep a record for three consecutive
days, including one weekend day (for
example, Thursday-Friday-Saturday or
Sunday-Monday-Tuesday). Advise the
client to choose three days that would
be typical of his or her usual intake
(to obtain the most accurate picture
of the client’s diet).
• The client should record everything he
or she eats or drinks during those days,
including water, any added salt, candies, gum, condiments, vitamin/mineral
supplements, sports drinks, coffee, tea,
medications, and alcoholic beverages.
• Use a separate sheet of paper for each
day and create columns with the following titles: Meal/Snack Time, Food/
Beverage & Amount, Food Group
Servings, Hunger Level, and Location.
• In the first column, record whether the
foods and/or beverages were part of a
meal (and which one) or consumed as
part of a snack.
Medical Information
1. How would you describe your present state of health?
q very well
q healthy
q unhealthy
q ill
q other:_____________________________________
2. Are you taking any prescription medications?
q Yes
q No
If yes, what medications and why?___________________________________________________________
Do these interact with foods or weight loss in any way?
3. Do you take any over-the-counter medications or supplements?
q Yes
q No
If yes, what medications and why?___________________________________________________________
4. When was the last time you visited your physician?____________________________________________
5. Have you ever had your cholesterol checked?
q Yes
q No
What were the results?________________________________ Date of test:__________________________
Total Cholesterol:__________ HDL:___________ LDL:___________ TG:____________
6. Have you ever had your blood sugar checked?
q Yes
q No
What were the results?_______________________________________ Date of test:___________________
7. Please check those that apply to you and list any important information about your condition:
q Allergies
(Specify: _____________)
q Amenorrhea
q Anemia
q Anxiety
q Arthritis
q Asthma
q Celiac disease
q Chronic sinus condition
q Constipation
q Crohn’s disease
q Depression
q Diabetes
q Diarrhea
q Disordered eating
q Intestinal problems
q Gastroesophageal reflux
disease (GERD)
q High blood pressure
q Hyper-/hypothyroidism
q Hypoglycemia
q Insomnia
q Intestinal problems
q Irritable bowel syndrome
(IBS)
q Irritability
q Menopausal symptoms
q Osteoporosis
Chapter 14
Figure 14-1
Sample
lifestyle and
health-history
questionnaire
q Premenstrual syndrome
(PMS)
q Polycystic ovary disease
q Pregnant
q Ulcer
q Skin problems
q Major surgeries:
q Past injuries:
q Describe any other health
conditions that you
have:_____________________
__________________________
__________________________
__________________________
Family History
8. Has anyone in your immediate family been diagnosed with any of the following?
q Heart disease
If yes, what is the relation:________________ Age of diagnosis:_____
q High cholesterol
q High blood pressure If yes, what is the relation:________________ Age of diagnosis:_____
q Cancer
q Diabetes
q Osteoporosis
9. What are your dietary goals?________________________________________+______________________
10. Have you ever followed a modified diet to manage a health condition?
q Yes
q No
If so, describe:____________________________________________________________________________
11. Are you currently following a specialized diet (e.g., low-sodium, low-fat)?
q Yes
q No
If so, what type of diet?____________________________________________________________________
12. Why did you choose this diet?______________________________________________________________
Was the diet prescribed by a physician?
q Yes
q No
How long have you been on the diet?________________________________________________________
13. Have you ever met with a registered dietitian?
q Yes
q No
Are you interested in meeting with one?
q Yes
q No
14. What do you consider to be the major challenges/issues in your diet and eating plan
(e.g., eating late at night, snacking on high-fat foods, skipping meals, lack of variety)?
311
Continued
15.How much water do you drink per day? ____8-ounce glasses
16.Do you have any food allergies or intolerance?
q Yes
q No
If so, what?_______________________________________________________________________________
17.Who purchases and prepares your food?
q Self
q Spouse
q Parent
q Minimal preparation
18.How often do you dine out or purchase take-out?____times per week
19.Please specify the type of restaurants for each meal:
Breakfast:________________________________________________________________________________
Lunch:___________________________________________________________________________________
Dinner:___________________________________________________________________________________
Snacks:__________________________________________________________________________________
Habits
20.Do you crave any foods?
q Yes
q No
If so, please specify:_______________________________________________________________________
21.How is your appetite affected by stress?
q increased q not affected q decreased
22.Do you drink alcohol?
q Yes
q No
How often? ____times per week
Average amount? ____glasses
23.Do you drink caffeinated beverages?
q Yes
q No
Average number per day _________
24.Do you use tobacco?
q Yes
q No
How much (cigarettes, cigars, chewing tobacco per day)?
25.Do you take any vitamin, mineral, or herbal supplements?
q Yes
q No
Please list type and amount per day:_________________________________________________________
26.Do you currently participate in any structured physical activity?
q Yes
q No
If so, please describe:
____minutes of cardiovascular activity, ____times per week
____strength-training sessions, ____times per week
____minutes of flexibility, ____times per week
____minutes of sports per week
List sports:_______________________________________________________________________________
27.Have you experienced any injuries that may limit your activity?
If so, please describe:_____________________________________________________________________
28.On a scale of 1–10, how ready are you to adopt a healthier lifestyle?
1 = very unlikely 10 = very likely ____________
Weight History
29.What would you like to do with your weight?
q lose weight
q gain weight
q maintain weight
30.What was your lowest weight within the past five years? ____lb
31.What was your highest weight within the past five years? ____lb
32.What do you consider to be your ideal weight? ____lb
q don’t know
33.What is your present weight? ____lb
q don’t know
34.What are your current waist and hip circumferences? ________waist ________ hip
35.What is your present body composition? ____% body fat q don’t know
312
Food
Description
Amount
Level of
Hunger (1–5)
Chapter 14
Figure 14-2
Sample
food diary
Note: 1 = Not hungry at all; 5 = Very hungry
Food/Beverage
& Amount
Food Group
Servings
Hunger
Level
Location
Other
Comments
Figure 14-3
Sample
food log
DINNER
SNACK
LUNCH
SNACK
BREAKFAST
Meal/Snack
Time
313
• In the first column, the client should
also record the time when all foods and
beverages were consumed. The client
should record everything immediately
after each meal or snack so that he or
she does not forget what was eaten.
• In the second column, the client
should give as much specific information as possible:
° Method of cooking (baked, broiled,
fried, boiled, toasted)
° Brand names of commercial products
° Specific foods and drinks
– Bread (whole wheat, white, rye;
number of slices per loaf)
– Milk (whole, low-fat, skim, proteinenriched)
– Margarine (stick, tub, diet)
– Vegetables (canned, fresh, frozen)
– Meats (fat trimmed, weighed with
bone, skinned)
– Drinks (light, low-calorie, diet, lowfat), including additions such as
cream and sugar
– Snacks (pretzels, chips, nuts, dry
roasted, raw)
– S ize of fruits or vegetables (small,
medium, large, extra large)
– Ingredients/condiments used in
salads and sandwiches (e.g., mayo,
ketchup, mustard, gravy, sauce,
grated cheese, salad dressing, lettuce, and tomato)
• The client should also list the amount
of food or beverage consumed, measured by a scale (for weight in ounces
or grams), a ruler (for height, length,
and width), or via a household measure (for volume: cups, tablespoons,
or teaspoons). If possible, the client
should weigh and measure foods after
preparation and indicate when it was
done. He or she can use package-label
information on commercially made
products.
• The client should also record any significant feelings or emotions he or she
was experiencing before and after eating, his or her hunger level, where the
314
food was eaten, and any obstacles that
were faced when making decisions and
choices.
Description and Procedure
Sources: Mahabir, 2006; Svendsen et al.,
2006; Willet, 2001
• The client records intake throughout
the day, including water and beverages. The client also records daily
physical activity. The client is solely
responsible for the foods consumed
throughout the day, as well as for
recording them.
• By reviewing food intake along with
the calories and fat consumed, the
LWMC can easily pinpoint any trouble
spots with food (e.g., late-night eating, meal skipping).
• The client must be very specific.
Instead of writing “ham sandwich,”
write down how much ham was actually
on the sandwich. Was it 3 ounces or (88
mL) 8 ounces (237 mL)? Include what
types of condiments were used, etc.
Necessary Components
• The client only needs to record his
or her food intake in a food diary
booklet, in a notebook, or on pieces
of paper. LWMCs should teach clients
that it is best to record food intake
immediately after consumption,
instead of writing it down at the end
of the day when it is easy to forget
foods consumed.
Pros
• Easy to administer
• Economical
• Increased awareness of habits and
foods consumed
Cons
• Dependent on the literacy of the client
• Respondent burden
• Recall bias; records may not reflect
“typical” intakes; interest in “pleasing” the facilitator may alter consumption or tracking
• Lack of knowledge on estimating portion sizes, calories, and fat content of
foods consumed
24-hour Recall
The same tools used for the food
diary can be used when administering
the 24-hour recall (see Figures 14-2 and
14-3). Obviously, a major limitation of the
24-hour recall is that “yesterday” may not
truly reflect the scope of a person’s typical
eating patterns. In addition, this tool relies
heavily on memory.
Sources: Resnicow et al., 2000; Schatzkin
et al., 2003
• Obtain information on food and fluid
intake for the previous day or previous
24 hours.
• The 24-hour recall is based on the
assumption that the intake described
is typical of daily intake.
• A five-pass method can be used that
includes the following
° A “quick list” pass in which the
respondent is asked to list everything consumed in the previous day
° A “forgotten foods” pass in which a
standard list of foods and beverages
that are often forgotten is read to
prompt recall
° A “time and occasion” pass in which
the time and name for each eating
occasion is collected
° A “detailed” pass in which the
detailed descriptions and portion sizes are collected and the time interval
between meals is reviewed to check
for additional foods
° The “final” pass—one last opportunity to recall the foods consumed
• Time that the food or beverage
was consumed
• The food or beverage item
• Serving size of the food or
beverage item
• How the food was prepared
Chapter 14
• Where the client consumed the food or
beverage item
• Any relevant notes regarding the meal
or food item
Pros
• Easy to administer
• Not dependent on the literacy of the
respondent
• Precision and, when multiple days are
assessed, validity
• Low administration costs
Cons
• The need to obtain multiple recalls to
reliably estimate usual intake
• Participant burden
• Difficulty of the estimation of
portion sizes
“typical” intakes; interest in “pleasing” the facilitator may alter consumption or tracking
Food-frequency Questionnaire
Food-frequency questionnaires (FFQ)
may be challenging for clients, as it can
be difficult to truly estimate the number of times an individual food is eaten.
However, the benefit of this tool is that
the client is less likely to forget foods,
because they are listed on the chart. It
is also easy to identify the type of diet
the client typically follows (e.g., low-fat/
high-fiber, high-protein/high-fat). Figure
14-4 presents a portion of a sample foodfrequency questionnaire.
Sources: Mahabir, 2006; Resnicow et al.,
2000; Schatzkin et al., 2003; Svendsen et
al., 2006; Willett, 2001
• The FFQ identifies foods that the client
most commonly eats.
• The client indicates, on average, how
much and how often he or she consumes different foods.
• Analysis of the FFQ data provides
information about the daily intake of
many nutrients.
315
Sample
food-frequency
questionnaire
Food
Every Day
(Always)
3 or 4 Times/Week
(Often)
Every 2 or 3 Weeks
(sometimes)
Don’t Eat
(Never)
Dairy Products
Milk, whole
Milk, reduced fat
Milk, nonfat
Cottage cheese
Cream cheese
Other cheeses
Yogurt
Ice cream
Sherbet
Puddings
Margarine
Butter
Other
Meats
Beef, hamburger
Poultry
Pork, ham
Bacon, sausage
Cold cuts, hot dogs
Other
Fish
Canned tuna
Breaded fish
Fresh or frozen fish
Eggs
Peanut butter
Grain products
Bread, white
Bread, whole wheat
Rolls, muffins
Pancakes, waffles
Bagels
Pasta, spaghetti
Pasta, macaroni and cheese
Rice
Crackers
Other
316
Food
Every Day
(Always)
3 or 4 Times/Week
(Often)
Every 2 or 3 Weeks
(sometimes)
Chapter 14
Don’t Eat
(Never)
Cereals
Sugar-coated
High-fiber (bran)
Natural (granola)
Plain (e.g., Cheerios®)
Fortified
Other
Fruits
Oranges, orange juice
Tomatoes, tomato juice
Grapefruit, grapefruit juice
Strawberries
Cranberry juice
Apples, apple juice
Grapes, grape juice
Fruit drink
Peaches
Bananas
Other
Vegetables
Peppers
Potatoes
Lettuce
Broccoli
Spinach
Carrots
Corn
Squash
Peas
Green beans
Beets
Other
Snacks and Sweets
Chips (potato, corn)
Pretzels
Popcorn
French fries
Cookies
Pastries
Candy
Sugar, honey, jelly
Soda, regular
Soda, diet
Cocoa
Other
317
• Vary among FFQs, but typically include a
large list of foods with their corresponding frequency of consumption
Pros
• Relatively low administrative costs
• Ability to assess usual and longer-term
intake
Cons
• Inaccuracy of absolute nutrient values
• Fluctuation of nutrient values depending
on instrument length and structure
• Lack of detail regarding specific foods
• General imprecision
“typical” intakes; interest in “pleasing”
the facilitator may alter consumption or
tracking
• Seasonal variability
• Cultural/diet variability (e.g., vegetarians, individuals on therapeutic diets)
Food Models and
Portion Estimates
A portion is the amount of food a person
chooses to eat, while a serving is a standardized amount of a food used to estimate
and/or evaluate one’s intake. Portions are
very difficult for some to estimate, and
correct estimates could mean the difference between a 1,400-calorie diet and a
2,200-calorie diet.
LWMCs can assist clients in a number of
ways when estimating their portions. The
guidelines presented in Figure 14-5 can be
used to help clients more accurately determine the amount of food that they are consuming (Wein, 2006).
In addition, there are a number of tools
that can be purchased to help clients better
understand their portion sizes. For example, the National Dairy Council sells paper
cutouts of various foods with detailed
nutrition information on the back. Also,
various companies sell plastic food models
that demonstrate average and large sizes.
Food models range from $2 for a single
food to $125 for an extensive package.
318
Some of these companies also sell index
cards with pictures of foods in specific serving sizes. The sizes range from 1-ounce servings to “supersize” servings, so clients can
visualize the difference and understand how
portion-size choices impact their diets.
Using the 2005 USDA
Dietary Guidelines
The 2005 Dietary Guidelines for Americans
provide science-based advice aimed at promoting health and reducing the risk for major
chronic diseases through diet and physical activity (United States Department of
Agriculture, 2005). The intent of the Dietary
Guidelines is to summarize and synthesize
knowledge regarding individual nutrients and
food components into recommendations for a
pattern of eating that can be adopted by the
public (see page 160).
These guidelines encourage most
Americans to eat fewer calories, be more
active, and make wiser food choices. A
basic premise of the Dietary Guidelines is
that nutrient needs should be met primarily through consuming foods. Foods provide
an array of nutrients and other compounds
that may have beneficial effects on health.
In certain cases, fortified foods and dietary
supplements may be useful sources of one or
more nutrients that otherwise might be consumed in less than recommended amounts.
Dietary supplements, while recommended in
some cases, cannot replace a healthful diet.
The following sections present recommendations for an active person or athlete. The
complete guidelines can be found at www.
health.gov/dietaryguidelines.
General Guidelines
LWMCs should review the following guidelines with their clients:
• Consume a variety of nutrient-dense
foods and beverages from the basic
food groups, while choosing foods that
limit the intake of saturated and trans
fats, cholesterol, added sugars, salt,
and alcohol.
Meat, Poultry, Fish
• 3⁄ 4 ounce equals:
Fruit
° Amount in a chicken wing
• 11⁄ 2 ounces equals:
° Amount in a chicken thigh
• 3 ounces equal
° Size of the palm of a woman’s hand
(3 x 31⁄ 2 inches)
°6
0 calories, or the size of a fist
° One large grapefruit
° Amount in a small chicken breast
° Size of a deck of cards
° Size of a checkbook
• 4 ounces equals:
° Amount in a sandwich
° Amount in a quarter-pound hamburger
° Amount in an Asian stir-fry
° Amount on an entree salad
° A restaurant chicken breast (6 inches across)
° Typical lunch or cafeteria portion
• 8 to 12 ounces equals:
° Common evening restaurant portion
Cheese
• 1 ounce equals:
° One slice on a sandwich or hamburger
° Amount on a small slice of pizza
° 1-inch cube, one small wedge, or a strip the
size of a pinky finger
° 3 tablespoons of parmesan
° 1 tablespoon of feta or shredded cheese
(salad bar)
• One serving equals:
°1
5 grapes or cherries
° One medium apple or orange (21⁄ 2 inches
across, or a little bigger than a tennis ball)
°O
ne small banana (6 inches, or the length of
dollar bill)
°1
cup of pineapple, blackberries, or
blueberries
• One small potato equals:
° 70 calories (21⁄ 2 inches long)
• One medium potato equals:
° 110 calories (4 inches long)
• One large potato equals:
° Typical restaurant portion
• One extra-large potato equals:
Fats
• One butter pat equals:
° 45 calories
• 1 tablespoon of mayonnaise equals:
° 100 calories (typical amount on a sandwich)
• 2 tablespoons of salad dressing equals:
° One small ladle (salad bar)
°O
ne-half large ladle (salad bar)
• 1 cup equals:
° Amount in side dinner salad
° Size of one baseball
• 2 to 4 cups equals:
° Amount on a salad bar plate
Source: Wein,
D. (2006).
SNaC Pack:
The Health
Professional’s
Guide to
Nutrition. www.
sensible
nutrition.com
Potato
Vegetables
° Coleslaw or beans at a barbeque restaurant
° Amount in a bowl of vegetable soup
Guidelines for
determining
food portions
°3
tablespoons of raisins (1⁄ 5 cup or
two miniature boxes)
°1
50 calories (typical amount on a dinner
salad)
° Cafeteria or restaurant portion
°S
ize of one-half of a baseball
Figure 14-5
°1
1⁄ 2 cups of melon or strawberries
°F
our dried prunes
° Amount on a large slice of pizza
• 1⁄ 2 cup equals:
Chapter 14
Beverages
• 11⁄ 2 ounces equals one jigger of an alcoholic
drink
• 4 to 6 ounces equals a typical juice portion
(restaurant)
• 6 ounces equals a glass of wine (restaurant)
• 8 ounces equals a common milk portion or the
size of one’s fist (2⁄ 3 soda can)
• 12 ounces equals one can/bottle of beer or
soda
319
• T o maintain body weight in a healthy
range, balance calories from foods and
beverages with calories expended.
•M
eet recommended intakes within
energy needs by adopting a balanced
eating pattern, such as the USDA Food
Guide or the DASH eating plan (see
Chapter 7). In other words, maximize
nutrient intake by choosing a wide
variety of nutrient-dense foods. This is
especially important for people who are
restricting their caloric intake to lose
weight. Choosing foods that are high in
calories and low in nutrients may mean
that the active individual is not adequately taking in appropriate nutrients
for performance (i.e., protein, complex
carbohydrates, B vitamins, iron, calcium, potassium).
• T o prevent gradual weight gain over
time, make small decreases in food and
beverage calories and increase physical activity. Also be sure to include
strength-training activities, which may
help to prevent a decrease in metabolism over time.
• Individuals who need to lose weight
should aim for a slow, steady weight
loss by decreasing calorie intake while
maintaining an adequate nutrient
intake and increasing physical activity. A good goal is to decrease intake
by 250 calories (e.g., 21⁄2 tablespoons of
butter or mayonnaise or a small order
of french fries), while increasing expenditure by 250 calories. Doing so will
promote a weight-loss goal of approximately 1 pound per week. Overweight
adults and overweight children with
chronic diseases and/or on medication
should consult a healthcare provider
about weight-loss strategies prior to
starting a weight-reduction program
to ensure appropriate management of
other health conditions.
Food Groups to Encourage
LWMCs should review the following
guidelines with their clients:
320
• Consume a sufficient amount of fruits
and vegetables while staying within
energy needs. Two cups of fruit and
21⁄2 cups of vegetables per day are recommended for a 2,000-calorie intake,
with higher or lower amounts depending on the calorie level. Fruits and
vegetables are high in complex carbohydrates, vitamins, minerals, and
fiber. Active people cannot train properly without adequate carbohydrates
in the diet.
• Choose a variety of fruits and vegetables each day. In particular, select
from all five vegetable subgroups (dark
green, orange, legumes, starchy vegetables, and other vegetables) several
times a week. Choosing a variety will
allow an active person to maximize his
or her nutrient intake, thereby reducing the need for supplements.
• Consume three or more ounce-equivalents of whole-grain products per day.
In all, Americans are advised to eat
6 ounces of grains each day with at
least half of the grains coming from
whole grains, based on a 2,000-calorie
diet. Whole-grain foods provide an
active individual with the complex
carbohydrates necessary to perform
endurance activities such as running
or biking and high-intensity activities
such as strength training or sprinting.
These foods also supply the B vitamins necessary for energy production.
In addition, many of these products
are fortified with iron, which also is
important for an athlete. Diets rich in
whole grains may reduce the risk of
heart disease and diabetes and help
with weight management.
• Consume three cups per day of fatfree or low-fat milk or equivalent milk
products. These products are low-fat
sources of protein, which is necessary
to promote muscle growth, and are
the most available sources of calcium,
which is important for bone health.
Fats
• Consume less than 10% of calories
from saturated fats and animal fats
and less than 300 mg/day of cholesterol, and keep trans fat consumption
as low as possible. Saturated fats,
trans fats, and cholesterol can clog
arteries and affect long-term health
and performance.
• Keep total fat intake between 20 and
35% of calories, with most fats coming
from sources of polyunsaturated and
monounsaturated fatty acids, such as
fish, nuts, and vegetable oils. Active
individuals need higher amounts of
carbohydrates (55 to 65% of total
calories) and protein (20 to 30% of
total calories), so limiting fats in the
diet is a good idea.
• When selecting and preparing meat,
poultry, dry beans, and milk or milk
products, make choices that are lean,
low-fat, or fat-free. Low-fat sources
of protein are the best choices for an
active individual’s long-term health.
• Limit intake of fats and oils high
in saturated and/or trans fats, and
choose products low in these fats
and oils.
Carbohydrates
• Choose fiber-rich fruits, vegetables,
and whole grains at each meal and
for snacks. Active individuals require
55 to 65% of total calories as carbohydrates, of which fiber-rich foods
are excellent sources.
• Choose and prepare foods and beverages with little added sugars or caloric
sweeteners. Added sugars may mean
more fluctuations in glucose level
(hypoglycemia or hyperglycemia),
which may affect performance.
Chapter 14
Sodium and Potassium
• Consume less than 2,300 mg of sodium
(approximately 1 teaspoon of salt)
per day.
• Choose and prepare foods with little
salt. At the same time, consume potassium-rich foods, such as fruits and vegetables. Highly active individuals may
sweat out more electrolytes and need
to replace them through their diet.
Alcoholic Beverages
guideline with their clients:
• Those who choose to drink alcoholic
beverages should do so sensibly and
in moderation, which is defined as the
consumption of up to one drink per
day for women and up to two drinks
per day for men. Alcohol may promote
dehydration, which may result in poor
exercise performance.
Addressing A Client’s
Nutritional Needs While
Staying Within the LWMC’s
Scope of Practice
M
aking specific nutrition/nutrient
recommendations and developing
meal plans are beyond the scope of
practice of an LWMC. However, providing
general nutrition information on nutrition
and weight management can be helpful
and useful for clients. An LWMC must know
when to tackle and when to refer nutrition
issues, as doing so will help maintain professionalism as well as decrease the risk of
liability (see Chapter 19 and Appendix A).
Table 14-1 features a list of issues that an
LWMC might discuss with clients, as well as
issues that are more appropriate for referral.
Every LWMC must ultimately determine what
topics are appropriate to discuss with the
client. An LWMC should not hesitate to refer
321
a client to a registered dietitian (R.D.) or
more qualified individual if the client’s needs
exceed the LWMC’s training and level of
expertise. Refer to Chapter 11 for more information on making appropriate referrals.
Table 14-1
Scope of Practice Guidelines for Nutrition
Appropriate Nutrition Topics for an LWMC
• MyPyramid Guidelines
• Suggestions for weight loss
• Pre-evaluations and use of
a food diary
• Lifestyle changes
• Hydration
• Recipes
• Support
• Basic pre- and post-exercise nutrition
• Weight-loss physiology
Nutrition Areas That Should Be Referred
• Specific meal plans
• Tailored plans
• Medications
• Diseases
° Cardiovascular disease
° Hypertension
° Hyperlipidemia
° Diabetes
° Eating disorders
° AIDS
• Medical diagnoses
° Anemia
° Osteoporosis
° Polycystic ovary disease
• Post-op
• Yo-yo dieting
• Supplements
• Large weight loss or morbid obesity
Qualified registered dietitians
can be located through the
following organizations and
channels:
•The American Dietetic Association
(www.eatright.org)
• SCAN Sports, Cardiovascular, and
Wellness Nutritionists (www.scandpg.org)
• Professional meetings
• Local fitness centers
• Medical professionals
• Professional networking
What do all of those terms
and letters mean?
• Nutritionist—A general term that
anyone can really use
322
• Registered dietitian (R.D.)—An
R.D. is an individual who has
completed certain related coursework, an undergraduate degree,
and an approved internship, and
has passed a national exam given
by the Commission on Dietetic
Registration (CDR). An R.D. also
completes yearly continuing education requirements.
• Certified specialist in sports dietetics (C.S.S.D.)— An accreditation
from the credentialing agency of the
American Dietetic Association
• Licensed dietitian/nutritionist (L.D./N., L.D., or L.N.)—
Requirements for these titles vary
by state. California, for example,
does not offer licensure to dietitians.
• Master of science or doctorate
degree (M.S. or Ph.D.)—LWMCs
should always check that the
degree was earned in a related
field (e.g., nutrition, exercise science, psychology) before making
a referral.
What questions should
the R.D. be asked?
• How does he or she stay up-to-date
on the latest research?
• Which organizations does he or she
belong to? What hospital or medical
group is he or she affiliated with?
• What journals or research does he
or she read?
• What are the fees? What is included
in the appointment?
• What is his or her area of specialty
or expertise (e.g., age groups, certain populations)?
• Does he or she sell vitamins, supplements, or foods?
• Discuss a current client situation
with the R.D. to get a better idea of
his or her approach or philosophy on
nutrition.
Nutritional Program
Planning for the
Weight-loss Client
Estimating Caloric Needs
There are a variety of methods that can be
used to estimate a client’s daily calorie needs.
Daily energy needs (caloric requirement) are
determined by three factors:
• Resting metabolic rate (RMR)
• Thermogenesis (calories required for heat
production)
• Physical activity
Resting metabolic rate is the amount of
energy (measured in calories) expended by
the body during quiet rest. RMR makes up
between 60 and 80% of the total calories used
daily. Physical activity is the second largest
factor contributing to daily calorie requirements. This is the most variable component
of RMR, as this number changes based on the
frequency, intensity, and duration of an individual’s workouts. Thermogenesis, also referred
to as the thermic effect of food, is the smallest component. This is the amount of calories
needed to digest and absorb the foods that
are consumed. While certain diets claim to
enhance this component (e.g., food-combining
programs), no research exists to support
that concept. The bottom line is that regular
physical activity is the most effective way to
increase the body’s caloric expenditures.
The following section reviews methods
for determining a client’s energy needs. This
information does not, however, take into
account a client’s disease risk in relation to
his or her weight or nutritional habits. For
more information on how to use tools such
waist-to-hip ratio and body mass index
(BMI), see Chapter 10.
Calculating Energy Needs
There are numerous ways to calculate a client’s daily caloric needs. The simplest method
is to multiply the client’s weight (in pounds)
by the appropriate conversion factor (Table
14-2). This calculation will yield an approxiAmerican Council On Exercise
Chapter 14
mation of how many calories the individual
needs to maintain his or her current weight,
based on activity level and gender.
The Harris-Benedict equation for basal
metabolic rate (BMR) takes into account the
individual’s weight, height, age, and gender.
However, it has been shown to slightly underestimate BMR in females and slightly overestimate BMR in males (Harris & Benedict, 1919).
Table 14-2
Conversion Factors for Estimating Daily Caloric
Requirements Based on Gender and Activity Level
Activity Level
Light
Moderate
Heavy
Male
17
19
23
Female
16
17
30
Light activity level: Walking (level surface, 2.5–3.0 mph), housecleaning, child care, golf
Moderate activity level: Walking (3.5–4.0 mph), cycling, skiing, tennis, dancing
Heavy activity level: Walking with a load uphill, basketball, climbing, football, soccer
Harris-Benedict Equation
For men: BMR = [13.75 x weight (kg)] + [5.003 x height (cm)] –
[6.775 x age] + 66.5
For women: BMR = [9.563 x weight (kg)] + [1.850 x height
(cm)] – [4.676 x age] + 655.1
Note: To determine weight in kg, divide weight in pounds by 2.2.
To determine height in cm, multiply height in inches by 2.54.
Incorporate an activity correction factor between 1.2 and 1.5 to
account for the individual’s average amount of physical activity.
Note: Multiply the BMR value derived from the prediction
equation by the appropriate activity correction factor:
• 1.2 = bed rest
• 1.3 = sedentary
• 1.4 = active
• 1.5 = very active
Table 14-3 includes several RMR prediction
equations that can be used to help clients
understand how many calories they burn
throughout the day while at rest. Some of
these equations provide more accurate results
for certain populations than others, so LWMCs
must be sure to choose the most appropriate
equation for each client.
323
Chapter 14 Table 14-3
RMR Prediction Equations (kcal/day)
Mifflin-St Jeor Equations
(Mifflin et al., 1990; Frankenfield et al., 2003; Frankenfield, Roth-Yousey, &
Compher, 2005)
Men: RMR = (9.99 x weight) + (6.25 x height) – (4.92 x age) + 5
Women: RMR = (9.99 x weight )+ (6.25 x height) – (4.92 x age) – 161
Multiply the RMR value derived from the prediction equation by the appropriate
activity correction factor:
1.200 = sedentary (little or no exercise)
1.375 = lightly active (light exercise/sports one to three days per week)
1.550 = moderately active (moderate exercise/sports three to five days per week)
1.725 = very active (hard exercise/sports six to seven days per week)
1.900 = extra active (very hard exercise/sports and a physical job)
Note: This equation is more accurate for obese than non-obese individuals.
Schofield Equation
(Schofield, 1985; Harris & Benedict, 1919; Tverskaya et al., 1998)
Age
Males
Females
15–18
BMR = 17.6 x weight + 656
18–30
30–60
>60
Note: This equation slightly underestimates for women and slightly
overestimates for men.
Owen Equation
(Owen et al., 1986; 1987)
Males: RMR = (10.2 x weight) + 879
Females: RMR = (7.18 x weight) + 795
Cunningham Equation
(Cunningham, 1991)
All subjects: REE (kcal/day) = (21.6 x FFM) + 370
Note: This is considered one of the better prediction equations for athletes because
it takes into account fat-free mass.
Wang Equation
(Bauer, Reeves, & Capra, 2004)
All subjects: REE (kcal/day) = (21.5 x FFM) + 407
Note: This equation is potentially better for athletes because it takes into account
fat-free mass.
Note: All methods of determining RMR are estimates only;
Equations use weight in kilograms (kg) and height in centimeters (cm);
REE = Resting energy expenditure; FFM = Fat free mass
In addition to the estimation equations
presented in Table 14-3, another method
called indirect calorimetry is used to pre324
dict resting metabolic rate. Since oxygen
is used in the metabolic process to create
energy, a person’s metabolic rate can be
determined by measuring how much oxygen he or she consumes when breathing.
There is a relationship between the body’s
use of oxygen and the energy it expends,
so scientists use formulas to convert gas
usage into energy/calories used.
Historically, oxygen-consumption measurements were only performed with a medical device called a metabolic cart, which can
cost between $20,000 and $50,000. Newer
technology has made it possible to measure
oxygen consumption using hand-held devices, making the analysis more accessible and
affordable.
Using Caloric Information
to Affect Weight
Once the client’s daily caloric needs
have been estimated, this information can
be used to help the client lose, gain, or
maintain weight. To change weight by 1
pound (0.45 kg), caloric intake must be
decreased or increased by 3,500 calories. For
weight loss, it is advisable to reduce daily
caloric intake by 250 calories per day and to
increase daily expenditure (through exercise) by 250 calories. This 500-calorie differ
ence, when multiplied by seven, creates a
weekly negative caloric balance that results
in a loss of 1 pound (0.45 kg). These numbers may be doubled to achieve a loss of
2 pounds (0.91 kg) per week, but that may
be too great a goal for some clients. Most
health organizations recommend a weightloss rate of 1 to 2 pounds (0.45 kg to 0.91 kg)
per week.
To gain approximately a 1⁄2-pound (0.23 kg)
of weight, clients can add 300 to 500 calories
to the daily intake. It is crucial that the exercise routine be maintained so that additional
calories are used to fuel muscles, rather
than to simply store additional fat. Advise
clients to follow this new calorie plan for a
few months and make changes as needed
(Baechle & Earle, 2008; American College of
Sports Medicine, 2010).
Chapter 14
325
Summary
T
he client interview is a time not only to
assess a client’s current dietary habits
and readiness for change, but also to
develop rapport and build a foundation for
the LWMC–client relationship. LWMCs should
understand which programming tools to use
with each client, as well as how to modify
those tools as needed. Finally, it is essential
for the LWMC to stay within his or her scope
of practice.
References
ACSM’s Resource Manual for Guidelines for
Exercise Testing and Prescription (6th ed.).
Philadelphia, Pa.: Lippincott, Williams & Wilkins.
Baechle, T.R. & Earle, R.W. (2008). Essentials
of Strength Training and Conditioning (3rd ed.).
Bauer, J., Reeves, M.M., & Capra, S. (2004). The
agreement between measured and predicted
resting energy expenditure in patients with
pancreatic cancer: A pilot study. Journal of the
Pancreas, 5, 1, 32–40.
Cunningham, J.C. (1991). Body composition as
a determinate of energy expenditure: A synthetic
review and a proposed general prediction equation.
American Journal of Clinical Nutrition, 54, 963–969.
Resnicow, K. et al. (2000). Validation of three
food frequency questionnaires and 24-hour
recalls with serum carotenoid levels in a sample
of African-American adults. American Journal of
Epidemiology, 152, 11, 1072–1080.
Schatzkin, A. et al. (2003). A comparison of a foodfrequency questionnaire with a 24-hour recall for
use in an epidemiological cohort study: Results
from the biomarker-based Observing Protein and
Energy Nutrition (OPEN) study. International Journal
of Epidemiology, 32, 1054–1062.
Schofield, R. (1985). Equations for estimating basal
metabolic rate (BMR). Human Nutrition: Clinical
Nutrition, 39C, 5–41.
Svendsen, M. et al. (2006). Accuracy of food intake
reporting in obese subjects with metabolic risk
factors. British Journal of Nutrition, 95, 640–649.
Frankenfield, D., Roth-Yousey, L., & Compher, C.
(2005). Comparison of predictive equations for
resting metabolic rate in healthy nonobese and
obese adults: A systematic review. Journal of the
American Dietetic Association, 105, 5, 775–789.
Tverskaya, R. et al. (1998). Comparison of several
equations and derivation of a new equation for
calculating basal metabolic rate in obese children.
Journal of the American College of Nutrition, 17, 4,
333–336.
Frankenfield, D. et al. (2003). Validation of several
established equations for resting metabolic rate
in obese and nonobese people. Journal of the
American Dietetic Association, 103, 9, 1152–1159.
United States Department of Agriculture (2005).
Dietary Guidelines for Americans 2005. www.
health.gov/dietaryguidelines
Harris, J. & Benedict, F. (1919). A biometric study
of basal metabolism in man. Key Facts in Clinical
Nutrition. Washington, D.C.: Carnegie Institute of
Washington.
Mahabir, S. (2006). Calorie intake misreporting
by diet record and food frequency questionnaire
compared to doubly labeled water among
postmenopausal women. European Journal of
Clinical Nutrition, 60, 561–565.
Mifflin, M.D. et al. (1990). A new predictive
equation for resting energy expenditure in healthy
individuals. American Journal of Clinical Nutrition,
51, 241–247.
Owen, C.E. et al. (1987). A reappraisal of caloric
requirements of men. American Journal of Clinical
Nutrition, 46, 75–85.
Owen, C.E. et al. (1986). A reappraisal of caloric
requirements in healthy women. American Journal
326
of Clinical Nutrition, 44, 1–19.
Wein, D. (2006). SNaC Pack: The Health
Professional’s Guide to Nutrition. www.
sensiblenutrition.com
Willett, W. (2001). Commentary: Dietary diaries
versus food frequency questionnaires—a case
of undigestible data. International Journal of
Epidemiology, 30, 317–319.
Suggested Reading
Kiem, M.L. et al. (1997). A descriptive study of
individuals successful at long-term maintenance
of substantial weight. American Journal of Clinical
Nutrition, 66, 239–246.
Wadden, T.A. et al. (2005). Randomized trial of
lifestyle modification and pharmacotherapy for
obesity. New England Journal of Medicine, 353,
2111–2120

Program Design And Implementation

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